the chronic care paradox - school of nursing.pptVIP

Quality care related to better survival among vulnerable older patients Higashi, Ann Int Med, 2005 Self-management programs for diabetes and hypertension improve outcomes Chodosh, Ann Int Med, 2005 Medication adherence reduces hospitalizations for diabetes, hypertension, hypercholesterolemia and CHF Sokol, Med. Care, 2005 Disease Management Observations Multiple definitions Small number of well designed studies Variable content, setting, duration and intensity of intervention Evidence weak Better for process than outcomes Utilization effects in both directions Not clear which DM elements work “The prevailing evidence appears to be that while disease management programs improve adherence to practice guidelines and lead to better control of the disease, their net effects on health care costs are not clear.” CBO, 2004 Paying for Good Chronic Care FFS does not fit chronic care philosophy No ability to invest Every item must become billable Managed care seemed to offer the ideal setting for chronic care principles, BUT it did not work as well as many had hoped Managed Care Strategies Favorable case mix selection Substitution Primary care investment Payment Issues Providers expect to be paid for what they do Who will invest in primary care Medicare as an HMO Expand coverage to include new services Monitoring Counseling Share savings from decreased inpatient/ER utilization Pay more per visit for fewer visits Pay for episodes instead of incidents Pay for outcomes Conclusions Chronic disease is here to stay More must be done to bring the health care system into alignment There is good scientific evidence to show better care is possible Managed care does not seem to be the magic carpet If managed care is to have any success, need better case mix payment system Changing the payment system is necessary but not sufficient How You Implement Is Important It Shouldn’t Be This Way: The Failure of Long-Term Care Robert L. Kane Joan West Vanderbilt University Press, 2005