Healthcare Ethicist: Pandemic Has Revealed Stark Inequities Around Chronic Disease
Even as the U.S. healthcare system necessarily pivoted quickly and dramatically to care for patients with COVID-19 and working to prevent transmission of the virus, activity related to the management of people with chronic illnesses fell backwards, says Marshall Chin, M.D., M.P.H., the Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine at UChicagoMedicine, and a general internist experienced in chronic disease management.
In a “Perspective” article, entitled “Uncomfortable Truths—What Covid-19 Revealed about Chronic-Disease Care in America,” published online in The New England Journal of Medicine on Oct. 23, Dr. Chin writes that, even as patient care organizations rushed to care for patients and manage the explosion in COVID-19 cases last year, “[H]ospitalizations for chronic conditions unrelated to Covid-19 and for emergencies such as appendicitis decreased. Mortality from dementia, cardiovascular disease, and diabetes increased; it’s unclear whether these trends reflected true increases or undercoding of Covid-related deaths. Rates of low-density lipoprotein cholesterol screening and glycated hemoglobin testing fell, as did new prescriptions for statins and metformin. Marginalized populations had disproportionately high morbidity from Covid-19, and survival rates were lower in underresourced hospitals in low-income neighborhoods than in well-resourced facilities. Addressing social determinants of health proved to be particularly important for good outcomes.”
Capturing a sports metaphor, Chin writes that “Bill Parcells, a coach famous for turning around bad football teams, once said, ‘You are what your record says you are.’ When it comes to managing chronic diseases such as hypertension and diabetes, the U.S. health care system’s performance is inadequate. Our outcomes reflect what the system rewards.” Indeed, he writes, “In football, quarterbacks and wide receivers get the glory for scoring touchdowns, but the battle is won in the trenches by the meat-and-potatoes linemen. Smart football teams invest in their lines. In health care, the glory and financial rewards go to surgeries and other procedures, devices, and medications and to the providers, health care delivery organizations, and companies responsible for these interventions. But the poorly reimbursed trench battles of chronic-disease management, which involve monitoring, coaching on self-management and behavior change, and mitigation of social needs, are critical for the vast majority of time that patients spend outside the clinic in their homes, communities, and workplaces.2 The U.S. health care system undervalues human relationships, connections, and longitudinal primary care, so it’s unsurprising that it falls short in this area. Technology and human capital will need to be integrated if we are going to deliver high-quality, patient-centered care.”
The reality, Chin writes, is that “Covid-19 has taught us important lessons that apply to chronic-disease care. First, our health care system excels at perpetuating its basic structure and supporting the powerful stakeholders who profit from this structure. We should, therefore, design chronic-disease systems to better support the health and experience of patients and the well-being of health professionals trying to meet patient needs. Payment for telehealth should support and provide incentives for integrated, holistic in-person and virtual care, and it should be administered using value-based models, rather than fee-for-service structures. We could create teams that assess, treat, and monitor patients, relying on the principles of effective, longitudinal primary care.2 We should also coach patients in self-management and behavior change and partner with communities to address social and structural factors impeding good health. Determining the ideal ratio of in-person visits to virtual visits, use of remote-device monitoring, and mix of health professionals will be important.”
So, what can be done? Chin makes numerous recommendations, among them:
Ø Ensure that patients are central and are the system’s compass
Ø Provide team-based care spanning home, community, outpatient, and inpatient settings
Ø Build strong partnerships with patients to address holistic issues and practical management
Ø Address systemic issues that drive inequities
Ø Be guided by a road map for advancing health equity
Ø Provide an appropriate mix of in-person visits, video or telehealth visits, and remove monitoring
Ø Provide flexible, up-front funding for chronic-disease care infrastructure, possibly involving capitation, per-member per-month payments, or bundled payments
Ø Tie retrospective payment to process and outcome measures that support patient-centered care and health equity
Ø Align public and private payers’ performance metrics to drive transformation and reduce providers’ administrative burdens
Ø Level the playing field for reimbursing components of chronic-disease care
Ø Provide adequate resource to safety-net clinics and hospitals
Chin notes clearly that his recommendations are “adapted in part from [a number of different] National Academies of Sciences, Engineering, and Medicine” reports.
Chin ends up with three key conclusions. “First,” he says, “our health care system excels at perpetuating its basic structure and supporting the powerful stakeholders who profit from this structure. We should, therefore, design chronic-disease systems to better support the health and experience of patients and the well-being of health professionals trying to meet patient needs.” What’s more, “Second, current reimbursement systems don’t adequately support the improvement of population health. We will need to level the playing field for chronic-disease care.” And, “Third, our chronic-disease systems are inequitable. Health care delivery organizations, payers, and policymakers should intentionally advance health equity and address structural racism. The health care system will continue to put people experiencing poverty and other marginalized populations at the back of the line unless we intentionally value and address their health.”
In the end, he writes, “The Covid-19 pandemic has forced us to step back, and the wider scenery has revealed uncomfortable truths about our chronic-disease systems. Too often, these systems are based on tradition, self-interest, and revenue generation — not on patients’ needs and health.” Instead, he says, “The health care system encourages and rewards what is valued — which should be supporting the health of all people with chronic disease.”
