According to a recent report from Agency for Healthcare Research and Quality (AHRQ, Rockville, Md.,) chronic diseases account for three quarters of the all national healthcare expenditures. Despite efforts, most Americans continue to receive care only for acute episodes. But change may soon be coming for these conditions.
“Meaningful use is very likely to require chronic disease management,” says Erica Drazen, Sc.D., partner in the Emerging Practices Group at Falls Church, Va.-based CSC. “I think this trend is related to payment reforms, and that's what's going to really motivate hospitals.”
Currently, many still view chronic disease management as coming under the purview of primary care. “I can't blame CIOs for feeling this is an ambulatory issue, especially when under the current DRG system the whole point of hospitalization is care in the hospital,” says Jaan Sidorov, M.D., Quality and Research Committee member and former board member of DMAA: The Care Continuum Alliance (Washington, D.C.). “That doesn't mean that the team of healthcare professionals doesn't have the responsibility to take care of the patient on a more global basis.” Sidorov maintains that the episode of care in the hospital should fit with what has happened before and after discharge.
Though still in its early stages, using IT for hospital-based chronic disease management (sometimes called disease or care management) is already being embraced by forward-thinking CIOs as a way to protect the bottom line while improving the health of patients.
One leader who sees the so-called writing on the wall is Rick Schooler, vice president and CIO of the eight-hospital Orlando Health system in Florida. “Care management is a new term for us,” says Schooler. “It's the way we're looking at our future in terms of our strategies to ensure that we don't have patients coming back to our hospitals for readmission for something that could have been handled proactively in the home.”
The problem until now is that, with a fee-for-service model, there has not been a business case for hospitals managing chronic care outside their four walls. But as Medicare moves to penalize hospitals by reducing payments for readmissions within a certain time frame, the business case is coming into focus.
“You haven't seen a lot of this because, quite frankly, it's not something that hospitals could make money at - the more patients come back, the more we admit and the more we get paid,” says Schooler. “It all comes down to the money.”
Schooler says he believes that dynamic will change as reimbursement models come into play which ding hospitals for having an out-of-sight, out-of-mind policy toward their patients. “Traditionally these are not money making services,” he says. “What they are going to be in the future is a way to prevent losing money because there will likely be no reimbursement for readmissions like this.”
There are exceptions, of course - most cite organizations with better-aligned payment paradigms like California healthcare giant Kaiser Permanente as an example of an institution that has found success. Phil Fasano, senior vice president and CIO of Kaiser, says it's all about mission and vision. “We're a preventive care organization and chronic disease management is just part of who we are,” he says. “It's part of the culture.”
But are hospitals, besides leading edge IDNs like Kaiser, beginning to take ownership of chronic disease management? According to Drazen, the answer is not yet - even with healthcare reform looming. “Unfortunately, not that many hospitals are thinking that far ahead, so they may do some things with ARRA money that don't help them respond to becoming an accountable caregiver,” she says. “The people really doing things are accountable care organizations already, like Kaiser.”
But Sidorov says he believes a shift is coming. “What I'm seeing nationwide is a greater emphasis on hospitals and their networks of primary care providers being turned into accountable care organizations,” he says. “The line that separates the outpatient care from the inpatient is breaking down; IDNs like Kaiser and Geisinger make sure that the transition is as seamless as possible.”
So how does Kaiser provide that seamless transition to ensure that chronic diseases are properly managed? In addition to the culture of the organization, of course, a big component is Kaiser's Epic (Verona, Wis.) electronic record - the central repository for the entire patient relationship, available to inpatient and outpatient providers, and to the patients themselves.
In addition to Epic, Fasano says Kaiser has created care registries - analytics tools used to support clinicians dealing with chronic conditions like diabetes - based on rules developed at Kaiser. Fasano says the registries are a suite of tools the organization built that analyze its data in Epic against Kaiser's evidence-based medicine preventive care protocols.