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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Fixing Disjointed Chronic Care

The US health care system does many things very well. But one thing it doesn’t do well is coordinate care over time and between sectors. Whenever a patient transitions from hospital to home or from hospital to nursing home or hospice, he or she is likely to end up confused and to encounter care glitches and perverse financial incentives. While the US health care system does a better job coordinating between sectors during illness episodes, better coordination between sectors over time is needed for Americans with lengthy illnesses.

Stuart Butler, PhD

Last year, I saw what many Americans face, when after excellent but ultimately unsuccessful hospital care for cancer, an almost destitute family member decided she’d rather go home to die peacefully than face more (expensive for everyone) treatment.  But frustrating licensing and Medicaid rules made it practically impossible for us, from many miles away, to arrange affordable and effective care for her at home. So she spent her final days, against her wishes and at considerable cost to taxpayers, at an inpatient Medicaid hospice.

Her story is not unusual. Even for patients leaving a hospital with a chronic but not terminal illness, the challenge of understanding and complying with complex discharge instructions can make it impossible to avoid a hospital readmission or costly nursing home care. Perhaps not surprisingly, when dual-eligible (eligible for both Medicare and Medicaid) elderly Americans enter a nursing facility—and their networks of friends and neighbors who might have enabled independent living start to erode—they are much likelier than other residents to remain there until death.

Why are there such problems with transitions between sectors in the United States? For starters, there is the perverse silo payment system for programs like Medicare and even many private insurers. This leads to a cost-shifting shell game that raises total costs and leads to disjointed and worse care. To avoid certain medical costs not easily reimbursable by Medicare, for instance, many long-term care facilities feel they must bounce residents back to the hospital for expensive “acute care” and “rehabilitation” care that will be covered by the hospital and Medicare.

Medicare and other payment systems also have encouraged costly hospital readmissions by covering multiple inpatient episodes without providing what one might call “after-sales service” that might prevent a recurrence.

Then there is the lingering fee-for-service culture of American medicine that still focuses too much on fixing things rather than on promoting health and coordinating the long-term management of illness. When you add to this fix-it mindset the disinclination of many physicians, even oncologists, to discuss palliative and hospice care until late in treatment, it’s not surprising that so many end-stage transitions are needlessly stressful, both emotionally and organizationally.

Fortunately, we can go down a much better and also less-costly road if we look at some interesting innovations and align payment incentives to them.

For example, while it is true that the Obama Administration’s recent Medicare readmission penalties for hospitals may be somewhat clumsy and even unfair, the rules are also spurring coordination. The New York Times reports on hospitals now calling discharged patients regularly, arranging physician appointments, sending medication reminders, and coordinating social services. The newspaper even reports that a UCLA Medical Center hospital care manager helped arrange a more accessible public housing unit for a stroke patient.

These efforts are likely to pay off in better care at lower cost. A recent study on transitional services for high-risk Medicaid patients in North Carolina found these patients were 20% less likely to be readmitted, thanks to such things as simply educating patients and families about managing chronic conditions and having a nurse follow up after discharge.

Leading-edge hospital systems like Geisinger in Pennsylvania are using vertical integration techniques to improve care while reducing costs by better managing transitions between levels of the health care system. For instance, the system, which also has its own insurance company, has paid for assistants in some physician practices to coordinate follow-up and reduce cost.

Geisinger also “embeds” physician assistants and nurse practitioners in more than a dozen Medicare skilled nursing facilities to manage resident care and avoid hospital readmission. It is piloting telemedicine services to tackle acute episodes in nursing homes that might otherwise lead to hospitalization. And having recently won a Medicaid contract in Pennsylvania, Geisinger is generally focusing on removing the silos between its hospitals and nursing homes.

Much more can be done to align hospital and physician services with the local community and empower many more patients with chronic conditions to live less expensively at home. When I was visiting a family member in England last year, he received a lengthy call from the district nurse, who called every couple of weeks to coordinate his treatment for congestive heart disease with the general practitioner, pharmacist, and hospital. The nurse discussed his diet, exercise, and temperament; asked how his wife was doing; and talked to both of them about his care. She also visited regularly. The century-old UK district nurse system provides a network of community-based skilled nurses who coordinate care, provide basic services, and support family members. When I was being brought up in England in the 1950s, everyone in the village knew the district nurse on her bicycle.

In some ways, America’s leading health systems are just catching up with this traditional approach to care coordination.

Other promising innovations here include Grand-Aides , who are state-certified individuals with medical training (such as nurse’s aides) and additional specialized training to work in the community. Other initiatives around the country show the enormous benefits of community-based coordination that bridges the gaps between hospital, physician, and a patient’s home community.

But all these promising approaches still face obstacles. Public and private payment systems typically do not properly reward initiatives by health systems or by community-based coordinators. Better clinical and performance information needs to be made available and explained to care coordinators dealing with patients who have chronic illnesses. And we need to reduce the firewalls between payments to hospitals, local providers, and social workers to encourage commonsense, less costly, and proven approaches to coordination.

About the author: Stuart M. Butler, PhD, is Director of the Center for Policy Innovation at the Heritage Foundation in Washington, DC, where he focuses on developing new policy ideas. Previously he served as Vice President for Domestic and Economic Policy Studies. He is also an Adjunct Professor at Georgetown University’s Graduate School.
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