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When it comes to prevention of chronic disease, what one policy change would have the greatest impact on moving from "promise" to "results?"

Contributors Respond

Kenneth Thorpe, Ph.D.

Kenneth Thorpe, Ph.D.

Chairman, Partnership to Fight Chronic Disease

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Chronic disease prevalence directly impacts our nation's health care system, economic well-being and overall way of life. More than one in four Americans struggle with multiple chronic conditions, including one out of every 15 children. For Medicare specifically, more than half enrolled in the program have five or more chronic conditions, which drives up health care costs and lowers the quality of life seniors enjoy. This is clearly a costly problem - for the 27 percent of Americans with multiple chronic conditions, almost $2 out of every $3 is spent on their health care.

Yet despite this unfortunate news, an opportunity exists. Patients with chronic conditions, especially those who have multiple, would benefit from integrated, collaborative care models that facilitate communication and incorporate treatment plans and comprehensive medication management. By embracing pro-health initiatives, such as those rooted in accountable care organizations, patient-centered medical homes and pay-for-performance, health care as we know it will move toward greater coordination of care.

Medicare delivery is one such arena that could benefit from patients having a streamlined, easy-to-access treatment regimen (this is especially the case with two out of three Medicare beneficiaries having more than one chronic condition). Unfortunately, while the crux of the solution is obvious, one provision of the Affordable Care Act - the Independent Payment Advisory Board (IPAB) - threatens to undermine this if allowed to move forward. IPAB is the 15-member panel with unprecedented power to change reimbursement structures. With 95 percent of Medicare spending due to chronic disease, long-term solutions that promote prevention and care coordination should be our top priority, not continued cuts to provider payments.

Above all, our health care system will benefit through an emphasis on patients who have multiple conditions, which will only reduce costs and improve millions of lives. Better coordinated care and recognizing what's working will help us reach overall goals and ensure quantifiable results.

Debra L. Ness

Debra L. Ness

President, NPWF

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When it comes to chronic disease prevention, the relationship between a physician and patient is paramount to ensuring appropriate, high quality patient care.  A patient’s physician is the most qualified to determine the most appropriate therapeutic intervention to treat the individual patient.  Individuals with heart disease often have multiple, chronic co-morbid conditions that require a full array of therapeutic interventions.  Health providers know best what therapies they intend to use to balance the various therapeutic and safety concerns in complex patients. Above all, helping patients remain healthy through research, education and care coordination is critical.

Martin Luther King, Jr., once said, “Of all the forms of inequality, injustice in health care is the most inhumane.” In the communities we serve, health disparities couldn’t be more real: African-American men and women have higher prevalence of hypertension and diabetes. Additionally, African Americans have a higher mortality rate for Cardiovascular Disease (CVD).

Our organization has set a goal that we believe is achievable if we all work together: reduce the Cardiovascular Disease disparity gap by 20 percent by 2020. To help make this a reality, we must assess specific steps we can take today, including improving access and treatment options for millions of Americans at risk of developing chronic diseases such as hypertension and heart disease.

Government-run health care programs like Medicaid play a significant role in providing such care. Within them, we must ensure access to a range of treatment options, particularly those that are the most effective. One approach that has dire implications as well as dangerous consequences requires that the least expensive drug in any class be prescribed to a patient first (known as “fail first”). As we all know, disrupting continuity of the most optimal care options can result in life threatening consequences for patients who are already the most vulnerable and can actually lead to increased symptoms, more medical complications, and higher health care costs.

Scientific research also suggests that there are racial, ethnic and gender differences in response to therapeutic interventions.  For example, certain beta blockers may work better in African Americans.  Restricting or otherwise limiting access to medications that may be more effective in treating racial and ethnic minority patients will only serve to perpetuate existing health disparities.  Basing treatment decisions on cost rather than clinical considerations ignores important variations that can exist in terms of safety, efficacy, and tolerability.

Better treatment and access initiatives are just two examples of how we can address this issue now and in the future. By focusing on the needs of patients, we will lay the groundwork for better health outcomes, less prevalence of disease, and achieving our goal of reducing the cardiovascular disease disparity gap by 2020. 

Mary Woolley

Mary Woolley

President, Research!America

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Nothing will do more to reduce chronic illness than a real, sustained investment in improving primary care. Many of the most prevalent and costly chronic illnesses can be delayed or avoided by supporting folks in engaging in more healthful behaviors that deter smoking, obesity, sedentary lifestyles, and other health problems.  Nothing does that more effectively than stable, high-quality primary care.

Primary care providers prioritize ensuring that patients access the preventive services they need – from immunizations to cancer screenings to contraception to STD and HIV testing to behavioral supports of all kinds. In a best-case scenario, these providers know their patients and understand their life circumstances, so they can help them access preventive services and engage in healthier lifestyles.  For some patients, that means overcoming fear about test results. For others, it means overcoming language barriers. For others, it means having culturally appropriate nutrition information and learning safe ways to exercise. For still others, it means finding a way to get screened without missing work and losing pay, navigating an impossible public transportation system, and paying for costly child care. 

The Affordable Care Act (ACA) makes a significant investment in primary care, which is a huge step in the right direction. It makes preventive services available without the costly co-pays, deductibles and other cost-sharing that have made these services prohibitive for so many. Thanks to the ACA, new private insurance plans are required to cover a range of recommended women’s services without cost-sharing, including well-women visits; screenings for gestational diabetes, osteoporosis, and colon cancer; pap smears and pelvic exams; breastfeeding support, counseling, and supplies; screenings and counseling related to interpersonal violence; and more. Private plans also must cover screenings and vaccinations for children without out-of-pocket costs. And Medicare must waive cost-sharing for many services and provide a free annual, comprehensive wellness visit that includes personalized prevention planning services.

The health care reform law also addresses the debilitating shortage of primary care providers by investing in training, incentivizing doctors to practice primary care, and increasing reimbursements for providing primary care services. 

If we are serious about getting health care costs under control, we simply must arrest the epidemic of chronic disease – and we will only do that, and provide genuine patient-centered care, by investing in primary care. 

Ness is president of the National Partnership for Women & Families.

Myrl Weinberg, FASAE, CAE

Myrl Weinberg, FASAE, CAE

CEO, National Health Council

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A shift in attitude among elected officials is necessary if this nation is to succeed in combating disease and stemming the rise of health care costs. Federal funding for the National Institutes of Health (NIH), the Food and Drug Administration (FDA), and other agencies that conduct medical and health research has not kept pace with scientific opportunity, jeopardizing our ability to find cures for deadly disease and to maintain our global competitive edge. Medical research has not risen to the upper ranks of our nation’s priorities in the halls of Congress; advocacy from stakeholders is critical to changing this.

Underfunded federal agencies that should be providing the catalyst for private sector innovation to help bend the cost curve are instead forced to cut and cut. Even as federal funding diminishes, the burden of disease rages on, exacting a tremendous financial and emotional toll on patients and families stressed by learning of delays in the next phase of promising research that could one day lead to cures. And not only are our elected officials giving too little attention to key federal agencies, they are not prioritizing policy-making that will incentivize the private sector to accelerate the development of new treatments and therapies for patients. There is a lot of talk about the value of innovation, but not a lot of action to stimulate it.  

What will it take to change this disturbing situation? We urge heightened awareness that medical research leads to better health outcomes and lower spending. Americans understand this simple equation — more than two decades’ worth of public opinion polling shows broad support for medical research, as well as, in recent years, heightened concern that we are not making as much medical progress as we ought to be. It’s hard to make progress with one hand tied behind the back of the research ecosystem, and with well-justified fears about the future of this enterprise in our nation, who can blame researchers for looking elsewhere for career options? This isn’t what the American public wants or expects.  

More than half of Americans are even willing to pay $1 per week more in taxes if they were certain that all of the money would be spent on additional medical research. We urge policy makers to recognize that Americans support a strong investment in research to improve health and ensure our economic prosperity. Without their leadership, the research enterprise in the U.S. risks continued foundering.

The citizenry of this nation would be well-served by sustained funding for the NIH, the FDA, the Centers for Disease Control and Prevention, the National Science Foundation, and the Agency for Healthcare Quality and Research. Each plays a part in the discovery and application of medical breakthroughs. And we would be well-served by a policy landscape favorable to private sector innovation in order to reap all the health and economic rewards of cutting-edge research and development conducted in this country.

When policy aligns with these goals, we will achieve the maximum benefit to patients and to our nation’s dual bottom lines:  healthier people and a healthier economy.  

Getting from here to there will require an understanding and appreciation among elected officials that research to improve health is the most direct path to a healthier future. It’s the responsibility of all the stakeholders in research to speak out to their elected representatives to make our case.

Bob Carr, MD, MPH

Bob Carr, MD, MPH

SVP & Corporate Medical Director, GlaxoSmithKline

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As we know, people with chronic conditions are a major cost driver of our health system. According to the Centers for Disease Control and Prevention, more than 75% of all health care costs are due to chronic conditions. Yet this segment of our population receives only 56% of recommended health care services, according to an article that appeared in the New England Journal of Medicine.

To improve the delivery of health care in this country and to control costs responsibly, we must address the needs of people with chronic diseases and disabilities utilizing a coordinated care approach.

An essential building block for such an approach would be the creation of individualized care plans (ICP), where a health care provider would employ comprehensive assessment tools to carefully consider the patient’s unique health history and lifestyle before recommending a treatment regimen.

The ICP would consider the patient’s age, gender, ethnicity, co-morbid health conditions, support systems, cultural and religious beliefs, ability or willingness to make changes in nutrition or exercise, and the ability to take on complex medication regimens or other therapies, to name only a few considerations.

People have different life goals, process health information differently, and require different treatment plans that address their conditions and their own particular biological make-up. Utilizing a coordinated care approach to help patients with chronic conditions better manage their health – as opposed to just treating their conditions in isolation – can produce better health outcomes. Some health programs in the United States have already demonstrated that this approach also results in more cost-effective care. It’s time to make the use of ICPs the norm in our health care delivery system.

Randy Beranek

Randy Beranek

President, CEO, National Psoriasis Foundation

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As an HR executive and medical director of a global business, I’m acutely aware that employees are—first and foremost—members of families and communities. With over 100,000 employees in 117 countries, GlaxoSmithKline is invested in their health and in the health of the communities where we operate. We regularly hear that our employees want to know not only what they can do to lead healthier lives but also what we can do as a company to improve the health of their own community.

We heard them loud and clear, and we are digging in, starting with understanding what it means and what it takes to be a healthy community.  We know we can’t do it alone. To really curb the tide of health care spending and prevent chronic disease, our country needs multiple stakeholders who care about improving health including private companies, non-profits, and government officials coming together to discuss what programs and policies are working well within communities and what can be replicated to create broad and sustainable results.

Last year we kicked off a program we call “Healthy Communities.”  We partnered with The Atlantic for “A Conversation on Community Health,” which brought together thought leaders in three cities to find out what they’re doing to build healthier communities, and also, what are the obstacles that, if removed, could accelerate collective action to improving the health of their own community?

In every city, we’ve heard that where individuals live has a significant impact on health. Inequalities diverge neighborhood by neighborhood, where education and access to resources – healthy food choices, green space, healthcare, public transportation – often determine the level of engagement citizens have in their own health outcomes.

It’s clear that we all need better insights, and we must look beyond access to health care for explanations.  Our existing strategies for preventing health challenges are not providing robust impacts.  Nor, for most cities, is there a rational alignment of the health system that remains a foundation for improving the community’s health. We need to focus on the role of public-private collaboration, the power of social determinants of health, and the need to build capacity to act collectively.

We’re on the start of this journey but by taking the best of what we’re learning, we can help be a part of the healthcare solutions our country needs, to give our employees opportunities to engage their own communities more meaningfully, and ultimately achieve something we can all support: a healthier America. 

Adapted from an interview with the Robert Wood Johnson Foundation New Public Health Blog.