Transition to where?

People with chronic disease bear the full brunt of the medical system’s fragmented care. This balkanization is encouraged by the way health-care providers are paid. Usually, no one is paid to manage a patient’s overall condition. Providers are paid for procedures, visits and dispensing prescriptions. There is no direct relationship between how much physicians earn and whether the patient improves. Chronic-disease patients see health-care providers in a number of unrelated venues, many of which do not communicate with each other.

Transitional care, which patients receive after discharge from a hospital or other health-care facility, occurs during an especially vulnerable period. Patients often do not understand the purpose of their medications or receive a detailed care plan. These oversights are especially critical in chronic-disease care because the conditions are managed largely by patients and their caregivers. As a result, nearly 1 in 6 is readmitted to the hospital within 30 days of having left a health-care facility. Hospitals are paid when again the patient is readmitted.

About 1 in 7 does not make a follow-up doctor appointment within four weeks of discharge. Patients’ physicians often are not informed about the details of the care provided in the hospital. About 1 in 5 chronic-disease patients say their physicians did not do a good job of communicating about their care.

Nearly 1 out of 4 was a victim of a medical error, and nearly two-thirds of those errors created a major problem.

Cheri Lattimer, executive director of the Case Management Society of America, does not like the term “discharge,” referring to when a patient leaves the hospital.

Hospitals should call their discharge paperwork a “transitions summary,” implying that it is a proactive care plan for the patient and provider.

“That summary must be sent to the next level,” Lattimer said. “The Joint Commission says 39 percent of documentation does not get sent to the next level. Transitions of care are not just from hospitals. It is an ongoing process. They say health care is a team sport, but we don’t know who’s on the team or who to throw the ball to.”

The chronic disease quagmire

The Congressional Budget Office (CBO) issued a disappointing report on the result of 10 Medicare demonstration projects designed to save money on chronic disease management. Chronic diseases account for about 75 percent of U.S. health-care costs. Six demonstrations centered on disease management and care coordination. Four used value-based payment by offering financial incentives to improve quality.

The CBO essentially said fee-for-service incentives to deliver high-volume care – and the lack of incentives for care coordination and system fragmentation – overwhelmed attempts at innovation.

Effective chronic-disease management is labor-intensive. Chronic disease hits hardest those people who are dually eligible for Medicare and Medicaid. These 7 million people have two of the greatest risk factors for ill health: being old and poor. They account for 42 percent of Medicaid costs and 25 percent of Medicare costs. Of the most expensive 1 percent of Medicaid enrollees, 83 percent have three or more chronic conditions, and about 60 percent have five or more. However, government reimbursement rates are inadequate to support disease management. The continually strapped Medicaid programs generally do not invest in these kinds of services unless they can provide immediate cost savings.

Previously, thirteen out of 15 Medicare pilot programs for management of chronic illness failed to reduce hospitalizations, which is a key aim of any such effort. The few successful programs had substantial in-person contact, which is expensive for the health-care provider and is generally not reimbursed well. Politicians become discouraged by so little success. Providers are equally discouraged by the effort’s expense.

Ultimately, solving chronic-disease management is a necessary – but not sufficient – requirement of getting health-care inflation under control.