Multiple Chronic Conditions: A New Paradigm for Approaching Chronic Disease

Transcription

1 Multiple Chronic Conditions: A New Paradigm for Approaching Chronic Disease American Medical Group Association October 26, 2012 Richard A. Goodman, MD Office of the Assistant Secretary for Health U.S. Department of Health and Human Services and Division of Community Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion

2 CDC Disclaimer The contents of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

3 Overview Context: The challenges of preventing, controlling, and managing multiple chronic conditions (MCC) HHS response: Federal actions to address to MCC Looking ahead: Issues in MCC

4 Multiple Chronic Conditions UNDERSTANDING THE BURDEN OF MCC

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6 The Challenge Persons living with chronic disease increasingly will mean persons living with multiple chronic conditions Health systems largely employ a "siloed" approach focusing on chronic diseases sequentially rather than in parallel Improving health outcomes and quality of life for persons living with chronic disease requires new coordinated approaches in prevention and management

7 Challenges in Coordination Between 2000 and 2002, the typical Medicare beneficiary saw a median of two primary care physicians and five specialists each year, in addition to accessing diagnostic, pharmacy, and other services. Patients with several chronic conditions may visit up to 16 physicians in a year. Patients take only about half of their medications as prescribed, and adherence decreases as the number of medications increases. Sources: Bodenheimer. NEJM 2008; Tinetti NEJM 2004

8 Percentage of All Americans Over One in Four Americans Have Multiple Chronic Conditions 25% 22.3% 20% In 2006, 28 percent of all Americans had two or more chronic conditions. 15% 11.8% 10% 7.1% 5% 3.9% 4.8% 0% Number of Chronic Conditions Source: Medical Expenditure Panel Survey, 2006; Adapted from Anderson G. Chronic Conditions: Making the Case for Ongoing Care, February 2010, Robert Wood Johnson Foundation.

9 Percentage of Population With Chronic Conditions Multiple Chronic Conditions Span the Age Spectrum Source: Medical Expenditure Panel Survey, 2006; Adapted from Anderson G. Chronic Conditions: Making the Case for Ongoing Care, February 2010, Robert Wood Johnson Foundation.

10 Average Per Capita Health Care Spending Health Care Spending Increases with the Number of Chronic Conditions Source: Medical Expenditure Panel Survey, 2006; Adapted from Anderson G. Chronic Conditions: Making the Case for Ongoing Care, February 2010, Robert Wood Johnson Foundation.

11 Prevalence of MCC 1 of 4 Americans Summarizing the Burden 2 of 3 FFS Medicare beneficiaries Access 16% of uninsured with MCC Outcomes As the number of conditions increase, so do: mortality, poor functional status, hospitalizations, readmissions, and adverse drug events Costs 2/3rd of U.S. health care costs for individuals with MCC 93% of Medicare expenditures for individuals with MCC Sources: Anderson, RWJF, 2010; Kronick, CHCS, 2009; Machlin, AHRQ, 2011; Warshaw, Generation, 2006; Lee et al, JGIM, 2007; Vogeli et al, JGIM, 2007; Wolff et al, Arch Intern Med, 2002; Chronic Conditions Chartbook, CMS, 2011

12 Multiple Chronic Conditions HHS ACTIVITIES

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14 DHHS Response to Multiple Chronic Conditions 2009: Established HHS Initiative on MCC, including Interagency Workgroup on MCC 2010: Developed and released HHS Strategic Framework on MCC : Implemented multiple activities within and external to HHS in support of advancing the Strategic Framework

15 Source: Strategic Framework Release: December 2010 HHS unveils public-private partnership to deal with multiple chronic conditions By Julian Pecquet - 12/14/10 12:30 PM ET The Department of Health and Human Services on Tuesday unveiled a new plan calling for increased collaboration between government agencies and the private sector to tackle the growing challenge of people with multiple chronic conditions. More than a quarter of all Americans suffer from several chronic conditions, according to HHS, such as arthritis, asthma, chronic respiratory conditions, diabetes, heart disease, human immunodeficiency virus infection and hypertension. Treating those patients takes up 66 percent of the nation's healthcare budget, adds HHS. But the nation's healthcare system is largely set up to deal with one disease or condition at a time, says HHS. That increases the risk of complications such as adverse drug reactions, unnecessary hospitalizations and overall confusion caused by conflicting medical advice. "Given the number of Medicare and Medicaid beneficiaries with multiple chronic conditions," said Medicare and Medicaid administrator Donald Berwick, "focusing on the integration and coordination of care for this population is critical to achieve better care and health for beneficiaries, and lower costs through greater efficiency and quality. The new Strategic Framework on Multiple Chronic Conditions seeks to resolve those issues by "fostering change within the system; providing more information and better tools to help health professionals as well as patients learn how to better coordinate and manage care; and by facilitating research to improve oversight and care.

16 Definitions Chronic conditions are conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living. Multiple: 2 or more Examples: Physical medical conditions (e.g., asthma, diabetes, heart disease) Substance use and addiction disorders Mental illnesses Dementia and other cognitive impairment disorders Developmental disabilities Source: Multiple Chronic Conditions: A Strategic Framework, 2010

17 Overarching Goals 1. Foster health care and public health system changes 2. Maximize the use of proven self-care management and other services 3. Provide better tools and information to health care, public health, and social services workers 4. Facilitate research to fill knowledge gaps

18 Goal 1: Foster health care and public health system changes Objectives A. Identify evidence-supported models for persons with MCC to improve care coordination B. Define appropriate health care outcomes for individuals with MCC C. Develop payment reform and incentives D. Implement and effectively use health information technology E. Promote efforts to prevent the occurrence of new chronic conditions and to mitigate the consequences of existing conditions F. Perform purposeful evaluation of models of care, incentives, and other health system interventions

19 Goal 2: Maximize the use of proven self-care management and other services Objectives A. Facilitate self-care management B. Facilitate home and community-based services C. Provide tools for medication management

20 Goal 3: Provide better tools and information to health care, public health, and social services workers Objectives A. Identify best practices and tools B. Enhance health professionals training C. Address MCC in guidelines

21 Goal 4: Facilitate research to fill knowledge gaps Objectives A. Increase the external validity of trials B. Understand the epidemiology of MCC C. Increase clinical, community, and patient-centered health research D. Address disparities in MCC populations

22 HHS Initiative on MCC coordinated by Office of the Assistant Secretary for Health

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24 HHS Initiative on MCC coordinated by: Office of the Assistant Secretary for Health Goal 1 NQF Measurement Framework for MCC NIA Universal Health Outcomes Measures for Older Persons with MCC Goal 2 NCOA Self-Management Alliance AoA Chronic Disease Self-Management Program initiative Goal 3 IOM Roundtable on Clinical Practice Guidelines and MCC Goal 4 FDA-sponsored report Inventory of Clinical Trials Protocols and Clinical Safety Data (focus on exclusion / inclusion MCC) HHS Data Initiative on MCC

25 Coordinated Data Working Group Why a coordinated data working group? Key partners include AHRQ, CDC, CMS and OASH Data systems NHIS National Health Interview Survey NAMCS National Ambulatory Medical Care Survey NIS / HCUP National Inpatient Sample (Healthcare Cost and Utilization Project) MEPS-HC Medical Expenditure Panel Survey Household Component CMS Medicare Administrative Claims Data

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39 Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition Baltimore, MD Top Five Dyad Chronic Condition Combinations among Medicare FFS Beneficiaries with at Least Two Chronic Conditions (N = 21,437,864): Prevalence and Per Capita Medicare Spending 2010 Five Most Prevalent Dyads Dyads Prevalence (%) Per Capita ($) High cholesterol and High blood pressure 52.9 $13,825 High cholesterol and Ischemic heart disease 36.2 $20,529 High cholesterol and Diabetes 32.3 $18,010 High cholesterol and Arthritis 31.1 $18,043 Ischemic heart disease and High blood pressure 29.6 $18,308 Five Most Costly Dyads Dyads Prevalence (%) Per Capita ($) Stroke and Chronic kidney disease 2.0 $51,715 Stroke and COPD 1.4 $49,025 Stroke and Heart failure 2.3 $47,568 Stroke and Asthma 0.4 $46,913 COPD and Chronic kidney disease 4.9 $45,011

40 Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition Baltimore, MD Top Five Triad Chronic Condition Combinations among Medicare FFS Beneficiaries with at Least Three Chronic Conditions (N =16,481,562): Prevalence and Per Capita Medicare Spending: 2010 Five Most Prevalent Triads Triads Prevalence (%) Per Capita ($) High cholesterol and High blood pressure and Ischemic heart disease 33.7 $19,836 High cholesterol and High blood pressure and Diabetes 29.9 $17,451 High cholesterol and High blood pressure and Arthritis 25.7 $18,238 High cholesterol and Diabetes and Ischemic heart disease 21.5 $25,014 High cholesterol and Ischemic heart disease and Arthritis 19.3 $24,539 Five Most Costly Triads Triads Prevalence (%) Per Capita ($) Stroke and Chronic kidney disease and Asthma 0.2 $69,980 Stroke and Chronic kidney disease and COPD 0.8 $68,956 Stroke and Chronic kidney disease and Depression 0.8 $65,143 Stroke and Chronic kidney disease and Heart failure 1.5 $63,242 Stroke and Heart failure and Asthma 0.3 $62,819

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42 Multiple Chronic Conditions ISSUES IN MCC

43 A Key Issue As prevalence of chronic conditions continues to increase in the total population, we face greater challenges in delivering care to individuals with MCC Accurate, reproducible, and understandable measures of the occurrence and impact of MCC will be essential to solving these challenges

44 Although the literature does not support a single uniform definition for chronic disease, recurrent themes include the non self-limited nature, the association with persistent and recurring health problems, and a duration measured in months and years, not days and weeks. Source: Thrall JH. Prevalence and costs of chronic disease in a health care system structured for treatment of acute illness. Radiology 2005; 235:9-12.

45 So far, many different approaches have been used to measure the prevalence and consequences of chronic diseases and health conditions in children, resulting in a wide variability of prevalence estimates that cannot be readily compared. Source: van der Lee JH, et al. Definitions and measurements of chronic health conditions in childhood: a systematic review. JAMA 2007;297:

46 Overarching Goals 1. Foster health care and public health system changes 2. Maximize the use of proven self-care management and other services 3. Provide better tools and information to health care, public health, and social services workers 4. Facilitate research to fill knowledge gaps

47 Summary Persons living with chronic disease increasingly will mean persons living with multiple chronic conditions especially among older adults. Government and non-government agencies and organizations that are examining implications for population-based public health action for chronic disease should explicitly incorporate approaches that address the increasing prevalence of MCC. The national Strategic Framework on MCC, reflecting broad stakeholder input, presents numerous guidance options relevant to development of a population-based public health action plan for persons to live well with chronic disease.

48 HHS Initiative on MCC: Key MCC Sites HHS Strategic Framework on MCC: CMS Chronic Conditions Chartbook: Systems/Statistics-Trends-and-Reports/Chronic- Conditions/index.html

49 Thank You The contents of this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy. National Center for Chronic Disease Prevention and Health Promotion Office of the Director