Chronic Care World: What a New California Report Tells Us About the Future of U.S. Healthcare

I’ve just finished reading an important new report published by the San Francisco-based California Healthcare Foundation, a healthcare policy think tank dedicated to spreading knowledge and ideas about healthcare policy and improving the healthcare system in the Golden State. The report, Californians with the Top Chronic Conditions: 11 Million and Counting, looks at five major chronic conditions—asthma, diabetes, heart disease, high blood pressure, and serious psychological distress—and how each of those conditions affects Californians. The statistics in the report are deeply sobering.

Among the report’s key findings:

About 40 percent of adults in California reported having at least one of the five chronic conditions studied.
High blood pressure is the most common of the five conditions, affecting about one in four, or 7.6 million, adults in California.
Of Californians with psychological distress, 34 percent delayed needed medical care, and 27 percent delayed filling prescriptions. Cost or lack of insurance was frequently cited as the reason for those delays.
The prevalence of chronic conditions increases with age. Of Californians age 65 or older, 70 percent have at least one chronic condition, compared to 26 percent of those age 18 to 39.
The proportion of California adults with chronic conditions did vary by region, from 36 percent in Orange County, compared with 45 percent of adults in the Inland Empire, San Joaquin Valley, and northern and Sierra counties.
In terms of age-based categories, 23 percent of 18-to-39-year-olds had one chronic condition; 31 percent of 40-to-64-year-olds had one; and 45 percent of 65-plus-year-olds had one. Meanwhile, 3 percent of the youngest corhort had two chronic conditions, 11 percent of the middle-aged cohort had two; and 20 percent of over-65s had two. Fewer than 1 percent of the youngest cohort had three of the five chronic conditions studied, 3 percent of the middle-aged cohort had three to five of the conditions, and 5 percent of over-65s had three to five of them
Meanwhile, interestingly, obesity was a huge factor in chronic illness, with 53 percent of those with three to five of the chronic conditions studied being obese, 46 percent of those with two chronic conditions, and 29 percent having one chronic condition being obese. Conversely, only 18 percent of those residents with none of the chronic conditions studied were obse.
And importantly, of those Californians with no usual source of medical care, 18.8 percent had serious psychological distress; 10.7 percent had asthma; 8.4 percent had high blood pressure; 8.1 percent had diabetes, and 6.6 percent had heart disease.

Here’s the thing: extrapolating these numbers nationwide—and California, statistically, actually has overall a considerably healthier population than many states—one can see the immense weight of chronic disease that will fall as a responsibility onto the U.S. healthcare system, and American society, in the coming decades. While only 9.6 percent of Californians are diabetic, some states have significantly higher percentages of diabetics: Arkansas (10.3 percent), Ohio (10.5 percent), Oklahoma and South Carolina (10.6 percent), West Virginia (11.1 percent), and Mississippi (11.7 percent), according to the federal Centers for Disease Control and Prevention (CDC)—and those are only the statistics for diagnosed diabetics (and if you’re wondering, Montana and Vermont have the lowest percentage of diagnosed diabetics, at 6.2 percent and 6.4 percent of their populations, respectfully—slightly above half the rate of Mississippi). Furthermore, rates of type 2 diabetes are now soaring among children nationwide.

What frightens policy, purchaser, and payer leaders the most is the explosion in the numbers of Americans with multiple chronic diseases, as clinical and policy experts alike agree that those individuals will need intensive care management and monitoring.

Not surprisingly, federal healthcare officials are using every opportunity to try to push providers forward to engage in population health management, and also to participate in outcomes measure-facilitated value-based purchasing initiatives. Very significantly, the SGR repeal legislation passed last month encompasses a huge change for physician payment incentives under Medicare, with a new incentive payment system, called the Merit-based Incentive Payment System (MIPS), which will drastically change how physicians are paid under Medicare going forward.

Providers moving forward to address care for high-risk populations

What is heartening is that pioneers in population health management and care management are learning a lot these days about how to begin to address the issues around care management for high-risk populations. It was fascinating to hear Antonio Linares, M.D., discuss the gains being made so far in the Blue Distinction Total Care Program, a care management, population health management and value-based delivery and payment program being sponsored nationwide by the Blue Cross Blue Shield Association of America. Most significantly, BCBSA and its affiliated Blues plans are providing participating physician groups with provider clinical liaisons and patient-centered care consultants, to help them effectively address the needs of these at risk populations, as Dr. Linares explained in a presentation at HIMSS15 earlier this month.

Meanwhile, I am extremely excited to be scheduled to moderate two important panel discussions in this area during the Health IT Summit in Boston, to be held May 12-20 in that city.

The titles of the two panels are “Analytics and Care Management Population Health management Strategies in 2015,” and “Advances in Patient Care through Big Data.”

Among the participations in the Analytics and Care Management” panel will be Mark Caron, the CIO of the Harrisburg, Pa.-based Capital BlueCross, whose organization has been wading deeply into the waters of population health and care management, and who will be sharing insights on what has worked and what hasn’t. With seven ACO-type contracts live (his organization refers to them as “ACAs”—“accountable care arrangements”), Caron and his colleagues already have a lot of learnings to share with their colleagues when it comes to leveraging analytics for population health management.

Meanwhile, one of the participants on the “Advances in Patient Care through Big Data” panel will be Bob Kay, director of population health at the Concord, N.H.-based Granite Health Network, a venture of five major integrated health systems in New Hampshire. Kay and his colleagues are just now plunging into the data-for-risk-contracting pool, but already have been learning a great deal about the challenges and opportunities inherent in that sphere.

What is abundantly clear, even this early on, is that population health management and care management are going to become increasingly embedded in the core ways in which the U.S. healthcare system functions, as our population ages and chronic illness grows even more prevalent—and as the overall cost of the system begins to approach unsustainability. The next decade will require a tremendous collective push forward in all these areas, and without a doubt, healthcare IT, business intelligence, and analytics will be absolutely essential to success in managing broad populations, at a time when our society needs its healthcare system to respond to all the population health—and cost—imperatives it faces.

I hope many colleagues will join us in Boston, as our discussions will be very important. And I look forward to sitting down with colleagues to share ideas in this critical area of endeavor not only for our healthcare system, but for our society as a whole.