The hard truth behind chronic care (and 5 ways to end the pandemic)

As accountable care organizations and providers start to absorb population health risks, chronic disease remains a daunting challenge. Typically lifelong and often lifestyle-affected, chronic diseases drive more than 75 percent of all healthcare spending. While success in this space is key to bending the cost curve, healthcare is failing at the task.

Half of all adult Americans have at least one chronic condition, and more than 20 percent have two or more. Most people with a chronic condition get worse, not better. The percentage of people with a chronic condition, those with multiple chronic conditions and the number of chronic conditions the sickest Americans have are all getting worse year-by-year.

One explanation for this dismal state of affairs is that the care system was designed around acute conditions. Despite this, the system doesn't work well for acute care, where patients feel confused by a series of physicians at their bedside with differing views. But it's genuinely awful for chronic diseases where the disparate information and lack of coordination pay out in different offices. The Center for Studying Health System Change reported that the average Medicare patient sees seven different physicians in four different practices every year. (It's bad for the physicians, too: a physician interacts with 229 other physicians in 117 practices annually, just to treat Medicare patients.) Care of chronic conditions is often triggered by an acute adverse health event, meaning the condition advanced and the patient is in a costly and ineffective care venue.

To break the downward spiral, providers need to transform their services, offering tightly integrated, lifestyle-focused, continuous care addressing patients' unmet health needs. Doing so will slow and sometimes even reverse the progression of chronic conditions.

How can providers achieve this? Five steps will start providers down a better path driven by the logic of improving value for patients.

Step 1: Start with patients. Acute care has been about doing things to patients, including tests, surgeries and procedures. While most providers are doing more to involve patients in decision-making, patients in the acute-care setting are recipients of care, and until discharge, rarely co-creators of health. Chronic conditions are different. The biggest health impacts often come from a patient's actions outside of the physician's office. Successful chronic disease care happens when teams of caregivers work with patients over extended time horizons and they co-create health.

While most providers describe their organizations as "patient centered," chronic disease makes clear just how meaningless that declaration generally is. Most care organizations are inwardly focused, evaluating problems and opportunities based on their own resources and not patients' needs.  

Reshuffling currently deployed assets into a different order or with a different emphasis won't change the trajectory of chronic disease. Organizations with rehabilitation services commonly include exercise and fitness in their chronic disease offerings. Those with occupational health incorporate onsite evaluations. Patients with chronic conditions like Type 2 diabetes or coronary artery disease might need exercise and workplace health services, but the real questions are what services are needed that don't now exist, and what changes or additions in services will remove the barriers to living in better health?

Organizations rarely start the design of their services with patients and patients' needs in mind, although some are involving patients in the care equation. To succeed, organizations need to talk with and study their patients, understanding and addressing the realities of their lives, challenges and unmet needs. Focus groups are not enough. It isn't simply patient satisfaction. Providers must understand patients' needs.

2. Address lifestyle, not behavior. The obstacle to overcome in chronic disease care isn't behavior; it's lifestyle. How and where patients live, what they eat, whether they smoke, how much they exercise, how much stress they endure and the limitations of their economic circumstances are just a few of lifestyle's dimensions. Lifestyles exist within a web of social relationships. Changing lifestyle factors is an awesomely difficult task.

Healthcare usually describes lifestyle challenges differently. It tells people to "change behaviors" but does so almost without regard to the social forces reinforcing the status quo.

Changing your diet, for example, is tremendously hard for a lone individual, but exponentially harder for someone who lives in a family, attends social functions or doesn't prepare his or her own food.  

Healthcare's weird blame game drives some of the behavior focus. Acknowledging healthcare's poor outcomes spurred a rush to assign fault. Payers sought a solution in "pay for performance," which caused providers to explain poor health outcomes as the responsibility of non-adherent patients. Health is co-produced by the individual's lifestyle and the care he or she receives. Clinicians need to work with this reality.

Healthcare improves value when it supplies solutions to patients' unmet needs and removes the obstacles to their health.

3. Structure around health-based segments. ZIP codes organize mail delivery. They don't work as the sole dimension for organizing healthcare.

Most healthcare is delivered locally, and most providers organize geographically. But healthcare needs stem from medical situations, around which truly patient-centric care should be organized. Healthcare's geographic orientation exacerbates the structural problems of fractured care delivery that is organized around facilities, procedures and medical specialties. Care doesn't align with how patients experience their medical conditions, and the structure makes delivering integrated solutions to patients' unmet health needs harder.

In recent years, care paths have emerged as a method to tame some of healthcare's structural madness. By recognizing that patients with similar symptoms or circumstances will need similar care, providers eliminate some of the chaos and dysfunction that affects the ad hoc teams which otherwise form when patients walk through the door. Care paths are a start, but only a partial solution.

Organizing around groups of patients with similar medical needs offers a higher-value solution. Co-locating services and tightly integrating teams of caregivers allows providers to improve efficiency and effectiveness. It also more readily enables the team to measure the health outcomes of their care.

4. Think health, not just medicine. Healthcare's purpose is better health. On the way to that goal, providers and payers get tangled in arbitrary distinctions that embrace some kinds of care as medical and exclude others as non-medical. It's a silly distinction. Decisions about what services are included, and which are excluded, should be made on the basis of whether they efficiently improve health outcomes for the people being served.

Many needs are not addressed by care that fits the typical definition of "medical." In the early 1960s, H. Jack Geiger, MD, established community health centers that became the model for the nation. At his clinic in rural Mississippi, Dr. Geiger realized malnutrition was a primary medical condition suffered by his patients. Drawing the ire of his federal funders, he wrote prescriptions for food and reimbursed local grocers who filled them. Responding to the inevitable challenge, he famously said, "The last time I checked my textbooks, the specific therapy for malnutrition was, in fact, food."

Dr. Geiger's example is important. He identified the problem underlying his patients' poor health and addressed it. One obvious reason that much of healthcare fails to improve health is that it misses important causes of poor health. Most cost less to address than their resulting illnesses cost to treat.

5. Leverage clinicians. Headlines regularly bemoan the nation's primary care physician shortage. While there are obvious issues, better structuring care to leverage physicians and other highly trained clinicians would dramatically reduce the magnitude of the problem.

To help organizations restructure care delivery, we ask clinicians to track for one day the activities not requiring their level of training and those activities they don't enjoy or do well. This identifies ways to leverage clinicians and make them more efficient and effective, and reveals opportunities to increase professional satisfaction and engagement, factors strongly correlated with higher patient satisfaction.

Provider organizations that structure care so clinicians practice at the top of their licenses gain tremendous leverage in the chronic disease space by using health coaches, educators, social workers, navigators or successful patients in their care delivery models. Health coaches at the innovative provider organization Iora Health maintain close relationships with patients and conduct most of the outreach to patients that, in the words of founder Rushika Fernandopoule, MD, "keep patients from getting into trouble." Others have patients participate in community group sessions teaching new lifestyle skills to manage the range of issues affecting day-to-day life and health. Successful patients know how to manage diets and exercise programs in ways that fit within a given community.  

The transition from volume-based strategy to value-based strategy requires a major mindset change. It doesn't happen instantly. These five steps each enable clinicians and organizations to experience success as they reset the compass from volume to value.

Scott Wallace, visiting professor of Family and Community Medicine at Dartmouth’s Geisel School of Medicine, and Elizabeth Teisberg, professor at Dartmouth’s Geisel School of Medicine and a senior institute associate at Harvard’s Institute for Strategy and Competitiveness, work in the U.S. and internationally with employers, healthcare providers, health plans, governments and others to conveniently and effectively treat chronic medical conditions, create employee health strategies and develop new health benefit and care delivery models to improve health.

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