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Commentary

You Can’t Get There From Here: Obstacles To Improving Care Of The Chronically Ill

By virtue of the nature of the illnesses with which it deals and the characteristics of the clients it serves, good chronic care is intrinsically much more difficult to achieve than is most good acute care. Good chronic care requires continuity over time, multidisciplinary teamwork, and boundary-spanning collaborations between medical and nonmedical service providers; reforming the delivery of chronic care will necessarily take a lot of time, require cooperation among a variety of folks generally unaccustomed to working with one another, and require disparate stakeholders to develop new ways of doing business.

The obstacles to improvement in chronic care can be classified into three broad categories. The first is the generic problem of changing the behavior of clinicians, further complicated in the case of chronic care by the multiplicity of clinicians involved in providing effective services. The second category is organizational design and performance, since new ways of delivering chronic care must be developed within a health care delivery system still largely oriented to—and preoccupied with—acute, short-term illness. Through what might be described as the "chicken and egg" dynamic, this second category eventually intersects the third, that of public policy, which impedes organizational reform in the health care delivery system in a number of subtle ways.

Changing Providers’ Behavior

 
The law of clinical inertia seems to be that physicians, nurses, social workers, and other health professionals, once established in practice, will continue to practice in much the same way unless affected by an external force of considerable magnitude. Guidelines promulgated by the National Institutes of Health (NIH) or specialty societies do not generally carry enough force.¹ Financial incentives provided by managed care plans generally contain enough force only for a minority of practitioners.² Advance directives from patients seem to carry hardly any force at all.³

When research or product development or a shift in the zeitgeist produce a consensus that the old way of doing things is inferior to some new ways, some professionals change their practice behavior immediately, and some never do. The behavior of the great majority who are at neither end of the continuum is highly contingent on a range of social, cultural, economic, and personality variables.⁴

This problem is compounded in the arena of chronic care by two factors. First, recognition of the importance of treating many chronic illnesses in a way that is intrinsically different from the response to most acute problems is a relatively recent phenomenon, one that has occurred subsequent to the training of a large proportion of health professionals now in practice. Adopting state-of-the-art approaches to chronic illness thus may require a more fundamental, and therefore more difficult, shift in mindset for many more experienced practitioners. Second, because of the importance of multidisciplinary teamwork in the care of serious chronic illness, changing practice patterns requires not only that providers change the way in which they practice, but also that they change the ways in which they work with other professionals—necessarily a more complex and daunting task.

Organizational Barriers

Top Changing Providers' Behavior Organizational Barriers Public Policy Barriers NOTES

 
The organization of the U.S. health care delivery system may leave a lot to be desired, but it seems to work relatively well for the management of heart attacks, broken bones, and diseased gall bladders. On the other hand, everyone seems to agree that the organizational status quo does not work particularly well for serious chronic illnesses. It is too fragmented, decentralized, and uncoordinated; except for a few paradigmatic, but rare, paragons of primary care, there is no one to take charge of, or responsibility for, all of the services required by an individual patient. Nor is effective interdisciplinary teamwork much more prevalent inside most health care organizations than out.

But it is far from clear what better systems of care for the chronically ill would look like. Which services are core, and which peripheral? Who should do case management? How should effective team-work be encouraged and nurtured? These and literally dozens of other questions of organizational design are largely unaddressed. Over the past three decades we have developed lots of prototypes, from specialized physician groups to the Program of All-Inclusive Care for the Elderly (PACE), but most of those have remained relatively small, locally idiosyncratic, disease- or population-specific, and remarkably fragile.

For a long time it was widely believed in the health policy community that the incentives encountered by fully capitated managed care plans were especially congruent with the attributes of high-quality chronic care, despite the fact that historically managed care plans treated disproportionately few persons with such illnesses.⁵ The data, however, have been much more equivocal.⁶ As in most things, it appears, variations in performance within the managed care world appear to equal, if not exceed, the difference between managed care and the rest of the world.

In the development of more effective organizational models for the delivery of chronic care, we have thus been caught, for more than twenty years, in a chicken-and-egg situation. Providers concerned with improving services to the chronically ill have sought to experiment with new organizational models and devices but have been frustrated by the unwillingness of most payers to support them; payers, on the other hand, feel that they are spending enough money on their chronically ill beneficiaries already and are reluctant to subsidize new organizational models that have not yet been thoroughly tested and evaluated. In the late 1970s and early 1980s both Medicare and many state Medicaid programs actually engaged in broad experimentation with new organizational arrangements for services to the frail elderly and disabled, but those efforts largely came to a halt in the early years of the Reagan administration and have not been resumed since. Instead, we have had stalemate and an absence of innovation.

Public Policy Barriers

Top Changing Providers' Behavior Organizational Barriers Public Policy Barriers NOTES

 
Public policymakers share with the provider community responsibility for this stalemate. They are responsible for other obstacles to service improvement as well. Perhaps the most visible arises from the fact that some five million of the most vulnerable persons with a high burden of chronic illness—the dually eligible—receive health insurance benefits from Medicare and Medicaid at the same time, and program administrators from both the federal and state governments have devoted a disproportionate share of their energies over the years to shifting costs and liabilities to one another, rather than to making the system as a whole work better for beneficiaries. The financing of long-term care, or other forms of chronic care services, thus has resembled a multidimensional, temporally endless game of hot potato, in which beneficiaries and the services they need are regularly tossed from one set of hands to another—and often fall on the floor in the process.

More subtly, but also quite importantly, high-quality care for the chronically ill requires continuity and stability over time, but both Medicare and Medicaid are designed around short-term interventions. The basic benefit package under Medicare Part A is still organized around a "spell of illness," which is by definition time-limited. Medicaid benefits, on the other hand, are rarely limited in duration, but eligibility is often quite unstable, especially since many of the chronically ill who receive Medicaid-paid services qualify for the program as medically needy; should their health care expenditures fall below a certain level, or their incomes increase, they are at risk for losing their health care coverage.

Finally, both Medicare and Medicaid are, of course, individual entitlements—although eligibility for Medicaid often hinges on the income of an entire family—while it is increasingly understood that serious chronic illness is something that happens to families and that effective patterns of care address not only the needs of the index patient but of his or her family members and caregivers as well. Our existing health insurance programs, by their very nature, are particularly ill suited to that challenge.

These obstacles to improvement of care for persons with serious chronic illnesses do not form an exhaustive list, although they may touch on the more important. Each is significant; taken together, they represent a formidable challenge. There is no logical or political reason why that challenge should be insuperable, but if we fail to adequately recognize or understand it and its components, the reform process is going to take a lot longer, and be more difficult, than is really necessary.

Editor's Notes

 
Bruce Vladeck is director of the Institute for Medicare Practice at the Mt. Sinai School of Medicine in New York City and senior vice-president for policy at Mt. Sinai NYU Health. He has also been professor of health policy and geriatrics at Mt. Sinai Medical School since 1997. Previously, he served as administrator of the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services). During 1997–1998 he was a presidential appointee to the National Bipartisan Commission on the Future of Medicare.

Work on this paper was supported in part by the Partnership for Solutions, a national program of the Robert Wood Johnson Foundation.

NOTES

Top Changing Providers' Behavior Organizational Barriers Public Policy Barriers NOTES

 

1. P.J. Greco and J.M. Eisenberg, "Changing Physicians’ Practices," New England Journal of Medicine 329, no. 17 (1993): 1271–1274.
2. T. Rice, "Physician Payment Policies: Impacts and Implications," Annual Review of Public Health 18 (1997): 549–565.
3. K.E. Covinsky et al., "Communication and Decision-Making in Seriously Ill Patients: Findings of the SUPPORT Project," Journal of the American Geriatrics Society 48, no. 5 (2000): S187–S193.
4. S.B. Soumerai et al., "Effect of Local Medical Opinion Leaders on Quality of Care for Acute Myocardial Infarction: A Randomized Controlled Trial," Journal of the American Medical Association 279, no. 17 (1998): 1358–1363.
5. C.C. Boesz, R.A. Armstead, and B.C. Vladeck, "Managed Care: A Foundation for Evolution," Health Care Management—State of the Art Reviews 2, no. 1 (1995): 5–18.
6. J.E. WareJr. et al., "Differences in Four-Year Health Outcomes for Elderly and Poor, Chronically Ill Patients Treated in HMO and Fee-for-Service Systems: Results of the Medical Outcomes Study," Journal of the American Medical Association 276, no. 13 (1996): 1039–1047.

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