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Chronic disease in America: Can we improve quality and reduce the cost?

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By mconnors via

By Brenda Kostelecky

Chronic illness is the most common reason people seek healthcare in the United States (1). Unfortunately, while the American healthcare system is often well equipped to treat acute injury and disease, it can be poorly suited to those with chronic conditions. Since the number of people with such conditions will increase as the American population ages, improving healthcare quality for patients with persistent conditions has become a key objective for many policymakers.

One of the major reasons people with chronic illnesses get short shrift is that financial incentives are heavily skewed toward acute care treatment (1). Healthcare plans tend to provide better coverage for treatments where the patient shows consistent, measurable improvement.  Such improvement is not necessarily possible for chronic conditions and may not even be the goal of treatment. Instead, slowing disease progression or maintaining a patient’s status (e.g. maintaining mobility with physical therapy) may be the only option available given the current state of medical science. Without adequate coverage for (and therefore access to) such treatments, chronically ill patients’ conditions often worsen and ultimately become more expensive. Another issue that disproportionately affects the chronically ill is that few healthcare plans offer reimbursement for time spent coordinating between care providers. This lack of financial incentive to coordinate care is particularly troublesome given that an average Medicare beneficiary with at least one chronic condition sees eight doctors per year (1). Lack of coordination frequently results in chronically ill patients receiving duplicate tests, differing diagnoses, contradictory advice and incompatible medications from different healthcare providers.

Several healthcare models aimed at treating chronic illnesses have demonstrated improvements in healthcare quality as well as reduced costs. One such model, the Medical Home Model, has been tested over the past 40 years in 100 diverse individual demonstrations (2). A medical home is defined by the Congressional Budget Office as a “clinical setting that serves as a central resource for a patient’s ongoing medical care” (3). Fields, Leshen & Patel identified factors common to seven successful medical homes and pinpointed four core elements these homes use to enhance efficiency and prevent complications (2). First, in all successful medical homes studied, a well trained, non-physician professional was specifically designated to coordinate care for an appropriate load of patients. Second, patients had round-the-clock access to providers to answer health questions and prevent avoidable emergency room visits. Third, the successful medical homes enhanced their use of information technology to track and monitor patients, evaluate practitioner performance, and predict which patients were at high risk for complications. Finally, a system of effective payments to incentivize coordinated care was implemented. These payments weren’t necessarily large and many successful programs didn’t offer significant performance pay.

Successful medical homes provide promising evidence that improved chronic care quality and cost reduction can be simultaneously achieved. However, there are many important challenges that lie ahead for policymakers. Scaling up and standardizing new healthcare systems from individual demonstrations will be complex; successful systems will need to suit urban and rural areas, regions with many non-native English speakers, and areas with large aging populations, etc. Policymakers need to identify which elements of model healthcare systems truly add value and focus efforts on implementing those pieces of the puzzle. It will also be challenging to provide financial incentives such that the proven value-adding elements are effectively utilized. The Patient Protection and Affordable Care Act (PPACA) of 2010 gives federal support to alternative healthcare models including medical homes. PPACA includes provisions to test new delivery and payment models and stipulates that resources for medical homes be provided for Medicare and Medicaid. If federal support continues, there is good reason to be optimistic that substantial improvements in chronic disease care quality can be achieved hand-in-hand with slowing the relentless rise of healthcare costs.


  1. Anderson & Knickman. Changing The Chronic Care System To Meet People’s Needs. Health Affairs vol. 20 no. 6 (2001):146-160.
  2. Fields, Leshen & Patel. Driving Quality Gains And Cost Savings Through Adoption Of Medical Homes. Health Affairs vol. 29 no.5 (2010):819-826.
  3. Congressional Budget Office. Budget options, volume 1: health care [Internet]. Washington (DC): CBO; 2008 Dec [cited 2010 Apr 10]. Available from:

Written by sciencepolicyforall

September 15, 2011 at 3:34 pm

Posted in Essays

Tagged with ,

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