BY J. MICHAEL BRODIE
As the senior population increases, American medicine faces a disease management problem that cuts to the heart of how care is organized.
The term disease state management has become a buzzword when applied to care of patients with multiple chronic conditions. It is a multi-step, coordinated systems approach to managing care processes for a specific high-cost and/or high-volume diagnosis, according to an AAFP position paper at http://www.aafp.org/x6710.xml. The idea is to improve outcomes and lower overall costs. This system requires a primary care physician, such as a family physician, as an overall care manager, says the Academy.
But two chronic care management demonstration projects included in the Medicare reform package passed by Congress late last year failed to recognize primary care physicians -- family physicians -- as essential care coordinators for these complex patients. One project focuses chiefly on shifting care to disease management organizations, while the other involves a "pay-for-performance" approach to providing chronic care.
The Partnership for Solutions, led by Johns Hopkins University and the Robert Wood Johnson Foundation, has estimated that about two-thirds of Medicare dollars -- nearly $170 billion -- are spent on participants with five or more long-standing conditions. Not surprisingly, many of those participants are elderly.
Commenting on the cost factor, AAFP Board Chair James Martin, M.D., of San Antonio said, "This is a startling figure for a program that not only costs taxpayers billions of dollars, but also is not geared toward chronic care management." He put this comment in a November letter to Rep. Nancy Johnson, R-Conn. She chairs the House Ways and Means Subcommittee on Health, which was studying the topic. She is also author of the provisions concerning chronic care programs.
The letter, available at http://www.aafp.org/x24988.xml, formed the basis of written testimony to the Senate Special Committee on Aging, which also held a hearing on the topic in November. "Examining 'what works' for chronic care is crucial as Medicare costs spiral upward and budget pressures to hold down spending increase," the Academy said in its statement to the Senate committee. Go to http://www.aafp.org/x25296.xml to read the statement.
The Academy is in the second generation of its quality enhancement program, Martin said in his letter to Johnson. The program was originally based on a chronic care model developed by Edward Wagner, M.D., Ph.D., director of the W.A. MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative of Puget Sound (in Washington).
The statement to the Senate committee noted that in November, the Academy convened an advisory committee to discuss specific initiatives to help family physicians design systems enabling them to enhance the quality of health care they deliver -- including care for chronic conditions -- as well as to document and be recognized for quality care.
Options discussed during the two-day session included offering family physician training through Web-based information, one-on-one interventions and innovative residency curricula. A newly created AAFP task force took up the concept again during the January cluster meeting in San Francisco.
"While a significant activity for a private organization, our focus on improving chronic care management for our members is only a fraction of what federal support could do to support disease care in the U.S. health care system," said Martin in his letter to Johnson.
The Academy’s concern is "that legislation focusing primarily on disease management companies, absent the integral role of an integrating physician, is counterproductive," he said. "We believe that federal support of disease management entities will take chronic care in the wrong direction."
What works, Martin offered, is a focus on improving chronic illness care within family physicians’ offices.
"If disease state management is ‘carved out’ by the managed care company and the family physician is not involved, then the patient loses the benefit of the family physician's knowledge of the patient's overall health status and problems," said Stephen Spann, M.D., professor and chair of the family medicine department at Baylor University in Houston. Spann is also medical director of the AAFP Annual Clinical Focus. The 2004 ACF topic is "Caring for America's Aging Population."
Spann said the more problems a patient has, the greater the complexity of care the patient needs. Managing some chronic diseases entails certain common elements, such as controlling blood pressure and lipid levels and maintaining a healthy weight.
"The family physician manages the multiple diseases and appropriate medical therapies, cognizant of potential drug-drug interactions," he said. "When specialists are consulted, they should report their opinion to the family physician, allowing the family physician to make the final decision regarding medication management."
To reach writer J. Michael Brodie, e-mail mbrodie@aafp.org.
FP Report is published by the
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Copyright © 2004 by
American Academy of Family Physicians.
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