Health Reform Must Include Real Reforms

Posted July 7, 2009 at 11:01am

As Congress returns to work from its July Fourth recess, lawmakers continue to struggle to reach consensus on several of the remaining key issues on health care reform and work to reduce the price tag in light of the sticker shock over the cost estimates of the draft Senate bills.[IMGCAP(1)]This has brought us to a critical point. If we are truly going to spend at least $1 trillion to provide coverage for the uninsured, we must act boldly to reduce costs. And in that regard, Congress has not yet shown leadership.In the current debate, there are a series of key questions that must be asked and answered. How do we reduce the high and rising cost of care and improve the quality of care? How do we provide insurance for the uninsured, and how do we pay for it?Though much of the early Congressional focus was on addressing high and rising costs by modernizing how we provide care to patients, the recent debate has centered almost exclusively on the price tag for covering the uninsured and what if any role a public health care plan would play. If we are to truly reform our health care system, we must also address the cost issue, because only if we address cost will we be able to provide coverage for the uninsured over the long term. Otherwise, all we will do is expand coverage that’s too expensive and not as high quality as it should be.Solving the cost issue requires understanding where we spend our money and what accounts for the rise in spending. Since 1985, the share of adults that are obese has doubled, and not surprisingly during that time, the rise in obesity accounted for nearly 30 percent of the growth in health care spending. In addition, more than 75 percent of our total health care bill is linked to patients with at least one chronic health care condition such as heart or pulmonary disease and diabetes.In Medicare, chronically ill patients account for 95 percent of total spending. Moreover, about 40 percent of the rise in spending among Medicare beneficiaries is linked to six chronic conditions: diabetes, hypertension, cholesterol counts, arthritis, pulmonary disease and depression, which are all often linked to obesity and are preventable.Today, despite these trends and facts, the traditional fee-for-service Medicare program pays nothing for the care coordination necessary to address these problems. As a result, Medicare is plagued with high rates of preventable hospital admissions and readmissions; 20 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, most of which are preventable.So the first task in health care reform should focus on developing new approaches based on proven methods to change behavior, slow the rise in chronic disease and deliver better care coordination. Appropriately designed, these ideas have been shown to reduce rising health care spending.An emerging idea in care coordination is the use of community health teams that work with physician practices to execute care plans for patients returning from the hospital to home or the nursing home assuring a smooth transition. They also would provide basic prevention services. Published trials have shown an effective transitional care function alone would reduce readmissions in Medicare. Based on research from the Medicare Advisory Committee and several published randomized trials, adopting a structured transitional care program as a key part of care coordination would reduce readmissions by 45 percent to 55 percent — saving $100 billion over the next 10 years.As both the private sector and federal investments in Medicaid to coordinate care have discovered, generating these savings requires a modest investment up front. Expanding the community health team concept to provide care coordination nationally for Medicare patients would involve a federal investment of about $25 billion over the next 10 years with the potential of substantial savings.Unfortunately, despite the early discussion about the need for greater prevention and delivery system reforms, the recent House proposal and the emerging Senate proposals do not make these modest investments that would modernize our health care delivery system, thus limiting the ability to truly transform how Medicare delivers care. The concern by Members of Congress is that investing $25 billion to coordinate care and provide better quality (which almost all agree will occur) may not produce savings, according to the Congressional Budget Office.However, leadership often means ruffling a few feathers. Despite the CBO’s concerns, published empirical evidence shows that investing in evidence-based approaches to coordinating care is the right way to reduce costs and improve quality for Medicare and other patients.What is ironic in this debate is that we are willing to consider spending far more than $1 trillion over the next 10 years to cover the uninsured, yet, despite ample evidence, we are not willing to make a modest investment to modernize our delivery system to reduce costs and improve quality for Medicare patients — this despite the fact that the federal government makes a similar investment in Medicaid.So as Congress and the administration recover from the initial sticker shock and consider the huge investment to cover the uninsured, I hope we do not lose the opportunity to include real “health— reform in the final package by making a critical investment in coordinating care for Medicare patients that will have a large payoff through better quality and lower costs.Kenneth Thorpe is the executive director of the Partnership to Fight Chronic Disease and is the Robert W. Woodruff professor and chairman of the Department of Health Policy and Management, in the Rollins School of Public Health of Emory University. He is also the executive director of the Emory Institute for Advanced Policy Solutions at Emory University.