The New Health Dialogue

We have written before about an interesting and ambitious initiative to improve care of low-income people with chronic diseases here in D.C., and some of the people involved allowed me to sit in on a brain-storming session earlier this week. The topic was self-care. How to get patients invested in, and capable of, managing their own chronic diseases. 

I didn’t speak up – I was an observer in this setting, a writer among health care workers. But as they talked about the systemic and economic barriers to providing the kind of care that low-income patients with chronic diseases, often with multiple chronic diseases, need, I kept having to bite my tongue. I kept wanting to say, “But health reform would fix that!! ” Or at least it would make a down payment on fixing it.  

Many of the health care professionals in the room -- from hospitals, community clinics, government agencies -- worked primarily with diabetes but some focused on cardiovascular disease (congestive heart failure, hypertension) , serious mental illness and substance abuse, HIV/AIDS (in this case, people with HIV/AIDS as well as other chronic conditions). The discussion began with the question -- is self-care important? Everyone agreed that it was. Particularly because many of these patients, with complex conditions only get to see their regular doctor for 10 minutes four times a year. They need to understand how to maximize their own health -- eat well, exercise, monitor their disease, take their medicine, count carbs (for diabetes), reduce sodium (for heart disease) -- All that good stuff that so many of us don’t do consistently, even when we know we should. Even those of us who have the ability and live in an environment where we can do so consistently --safe neighborhoods where we can exercise, grocery stores that carry abundant fresh produce, access to medical care.

Poverty or low-income isn’t necessarily the only obstacle to good disease management. Plenty of well-educated people with good insurance don't take care of themselves, and end up making repeat visits to emergency rooms. (See any upper middle class couch potato). People on Medicare by definition have insurance, but Medicare has a big problem with hospital readmissions (addressed in the health reform bills!) But poverty does add another layer of challenges – or several layers. Well-insured people don’t end up in the ER on the last week of every single month because they run out of money and can’t buy their insulin. (For some Medicare patients, who fall into the drug coverage “donut hole,” health reform may give them extra help with insulin and prescription costs.)

People taking part in the discussion floated a lot of ideas -- ranging from an 800 number for chronic disease, like the quitlines that  help people trying to quit smoking to the need for a personal touch in trying to change behavior over the long haul. But the conversation kept coming back to: “We can’t do that,” “We have no money to do that,” or “We don’t get reimbursed for doing that.” Yet everyone in the room realized there is money to be saved. If the system allowed spending money on the services needed to save the money.

For instance, one doctor in the room described a D.C. clinic that treats mentally ill people. It has more than 150 patients covered in one health plan, but about two dozen of them are responsible for more than $1 million in hospital costs -- or 80 percent of the hospital spending for that group of patients (for medical problems like diabetes, not their mental illnesses or behavioral health issues). Care managers might bring down those costs. But no one is paying for care managers.

Health reform legislation won’t wave a magic wand and eliminate chronic disease. It won’t cure diabetes. It won’t make fat people thin. It won’t wipe out HIV or keep failing hearts beating. But it would pay more for primary care. It would bolster and expand Medicaid. It would create medical homes, where care coordination and follow up care is paid for. It would help with tobacco cessation. It would expand and make more affordable preventive care. It would give incentives to hospitals to curb readmissions, and to transition people better from hospital to home, or hospital to rehab, or hospital to nursing home.  It would give health care providers the tools, and the incentives, they need to help patients learn to take care of themselves. It would, as one doctor said, make it easy to do what’s right.