Health Reform Ideas Are Treading Water

If you ever got the idea that health reform efforts have been treading water for years, if not decades, you will feel vindicated by a recent study on disease management and an article about “shared medical decision-making.” Both of them tell us what we’ve already known for a long time:

1. Chronic disease management, as currently practiced, doesn’t save money or improve the quality of care very much.
2. Shared decision-making can lead patients to make decisions that are cost-saving.

The JAMA study on Medicare’s demonstration project on disease management is entitled “Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries.” The term “care coordination” was apparently chosen because it is related to the currently trendy “advanced medical home” concept. But it’s still classic disease management, in the form that health plans do it. Because most private practices have neither the resources nor the incentives to follow the “chronic care model” of group-model HMOs, the insurance companies hire outside disease management firms. These companies have nurses call very sick patients to make sure they’re taking their meds and following their treatment plans. The nurses sometimes call the patients’ physicians, who may or may not pay attention. This is the model that was tried out in the fee-for-service Medicare program.

As was reported a couple of years ago, the demonstration project was a bust. The JAMA study, which details this failure, notes that thirteen of the 15 pilot programs showed no significant differences in hospitalization between the control group and the study patients, most of whom had congestive heart failure, coronary artery disease, and diabetes. In only three of the programs were there cost savings, ranging from 9 to 14 percent, and those savings offset service fees in just two programs. And this is only one of many studies showing that disease management delivers less than it promises.

Randall Brown, one of the paper’s authors, commented, “The only way you can really do it [achieve better results] is by changing patients’ behavior and by changing physicians’ behavior, and both things are really hard to do.” Well, agreed, but it’s even harder to change physicians’ behavior or have them do more for patients if they’re not involved in the program. And they won’t be unless we make it worth their while and put them in an environment where they can actually coordinate care effectively.

Even more disheartening is an AP article about shared medical decision-making. There’s nothing wrong with the piece, which explains how patients could make better choices if their physicians gave them more information and were open to letting patients share in the decision-making. But as I read it, I had the sinking feeling that it could have been written in, say, 1994. Even though the writer suggests that today’s patients are more “savvy” because they look up health information on the web, I see no sign that Americans, on the whole, are making better choices than they did 15 years ago. Nor is there any indication that shared decision-making, as defined by experts like those at Dartmouth Medical School, has spread beyond a handful of physicians.

The sad truth is that we know what we must do to fix these problems and to save our health care system. We’re just not doing it.