Perspective: Team approach to care of chronic conditions is key to long-term health system fix

Kenneth E. Thorpe, PhD, the Robert W. Woodruff Professor and chairman of the Department of Health Policy and Management at the Rollins School of Public Health at Emory University, Atlanta, Georgia, recently spoke with Medical Economics Editor-in-Chief Lois A. Bowers, MA.

Q: As deputy assistant secretary for health policy in the U.S. Department of Health and Human Services, you were really involved with health reform efforts during the Clinton administration. How does that effort compare with the Affordable Care Act?

A: The pooling of risk is a similarity. They’re called exchanges in the ACA. Under the Clinton administration, they were called alliances. But they were similar in concept. The place where they are primarily different is on the cost containment component. In the Clinton plan, there were very big reductions in the growth of private insurance premiums that were built into the legislation.

Q: What needs to happen in the healthcare system to get costs under control?

A: One of the key drivers of rising healthcare spending is the explosion in the prevalence of chronic helthcare conditions like diabetes, pulmonary disease, and depression. Many of them are potentially preventable. Any serious reform effort has to focus on doing a better job of preventing the rise in chronic disease prevalence in the future.

     Also, 84% of overall healthcare spending is associated with patients who have one or more chronic healthcare conditions. The challenge is how best to manage those patients to keep them out of the hospital, keep them from being readmitted or going to the emergency room and clinics. We just don’t really do a good job of that today. The Medicare program has no care coordination at all, which makes no sense. We really need to build health teams with nurses, nurse practitioners, social and mental health workers, and pharmacists to work with provider practices to engage patients once they leave a physician’s office. They can manage those conditions and make sure patients understand what the care plan is and are refilling their prescriptions appropriately and so on. Things that don’t really happen today because they’re not paid for.

     And we need to start changing how we pay. The faster we move away from paying on a fee-for-service basis, the faster we’ll have reforms that really are building more integration between hospitals and ambulatory care providers and patients’ health.

     The key long-term to pulling costs out of the system is improving outcomes. We need to focus the entitlement reform debate, the healthcare reform debate, on those key structural issues and move it away from simply slashing payments to healthcare providers, which is not a long-term strategy and doesn’t pull a dime of costs out of the system.

Q: At the practice level, what can individual physicians or practices do to help contribute to cost savings?

A: Medicare just added a new CPT-4 code for transitional care, care for a patent who comes out of the hospital. A transitional care nurse works with the patients at discharge and at home, again, to kept them healthy, keep them from having to be readmitted to the hospital. So physicians may want to start looking into hiring or contracting with a nurse or nurse practitioner to provide transitional care, because now physicians can bill for it.

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