Chronic disease is omnipresent in the United States. Trillions of dollars are devoted to and hundreds of thousands of lives are taken by chronic conditions each year.
So why does it feel like we are going backward, with falling life expectancy, and higher prevalence of chronic diseases?
The pandemic, for one, has been an accelerant, setting people’s health back and hampering health care more broadly in the fight against disease. But it has also offered valuable takeaways, and ideas for how to get ahead of disease, especially in under-resourced communities.
A panel of experts convened at the Milken Institute Future of Health Summit in Washington this week to discuss the many problems and shortcomings of chronic disease care, and how making changes upstream could improve the health of the population. (A STAT reporter moderated the discussion.)
“We were in a pseudo- or full lockdown for almost two years, and the impact on patient psyche and people’s mental health across the nation I think has helped accelerate this … because people are tired,” said Arta Bakshandeh, a physician and chief medical informatics officer at Alignment Health.
People’s exhaustion is reducing their capacity to manage chronic conditions, and is contributing to mental health concerns that do the same, he said. “It’s adding fuel to the fire, essentially,” he said. “It’s an accelerant.”
Factor in people’s behaviors during the pandemic, including more alcohol consumption, reduced movement and exercise, extra stress, and delayed preventive care and health screenings. Consider the decline in child immunizations, and the entry of anti-vaccine, anti-science rhetoric into the mainstream. “There’s going to be a big tsunami just around the corner, I fear, on chronic conditions,” said Donna Grande, CEO of the American College of Preventive Medicine.
It will take more than burned-out providers to manage what’s coming, the panelists said. The pandemic actually helped illuminate some novel paths forward.
For Eli Lilly, the pandemic was a lesson in speed, said Derek Asay, senior vice president of Lilly Value and Access. In the spring of 2020, when Lilly had identified a Covid antibody and needed to reach patients for clinical trials, the company bought a fleet of RVs, which became mobile research units. Now, the company is using a similar method to reach Alzheimer’s patients, and make clinical trials more inclusive.
The Centers for Medicare and Medicaid Services and its CMS Innovation Center is trying to reimagine the use of programs and tools it rolled out over the past two and a half years. Telehealth is one, but the Innovation Center is also exploring value-based care arrangements that made flexible payments to providers, Dora Hughes, the center’s chief medical officer, said. “Now in this environment, we’re increasingly providing flat payments or capitated payments,” instead of paying providers for the volume of services — a change that helped providers stay afloat during lockdowns, she said.
A major issue in health care, but especially when it comes to chronic disease care, is the availability of good, robust, consistent data, panelists said. Bakshandeh imagines a future where data is “democratized,” so it flows from CMS to providers, doctors, patients — a unified data architecture where all relevant parties can see a patient’s medical history and other key information, and more quickly act on it. “That would be bliss,” he said.
There are other data gaps, too. Little is known or formally documented about patients’ lives outside of the health care system, on how behavioral, socioeconomic, geographic, genetic, and other factors could impact long-term health.
How do a patient’s symptoms flow during the 23 hours they are not at their doctor’s office? Health tech, like smartphone app, blood glucose, and blood pressure monitoring tools, could document that, Asay and Bakshandeh said.
CMS, for its part, is redoubling efforts to collect demographic information on Medicare and Medicaid beneficiaries, but also on their social needs, such as housing, food, employment, and more. Medicare is also opening its arms to historically unrecognized providers, such as peer counselors, community health workers, doulas, and even pharmacists, as part of primary and specialty care, Hughes said.
Community-based approaches, even seemingly nonmedical interventions, like adding safe walking streets and farmer’s markets, could help improve the health of whole ZIP codes, Grande said. But to do so, population-level data from local and regional hospitals and other sources needs to be analyzed and used.
Meeting patients’ urgent needs
Chronic disease often begins long before the diagnosis. It begins, sometimes, in homes full of disease-causing pests, cities ravaged by natural disasters, or towns without doctor’s offices and nearby grocery stores.
So getting ahead of the nation’s chronic disease problem means addressing problems early. As a physician, Bakshandeh visited patients in their homes and found impoverished neighborhoods full of bedbugs, cockroaches, and water leaks. People couldn’t afford pest control or plumbers, and they would then develop illnesses or infections as a result. Instead of waiting until issues festered into a blisteringly expensive visit to the emergency room, Bakshandeh thought, “Maybe I can call a plumber to fix the leak that’s causing this outbreak of Legionella that’s giving you pneumonia.”
Likewise, providers (and payers) should meet patients at their level of food literacy, panelists said. Misleading food labels, confusing nutritional information, and little education about diet means Americans are left in a gulch.
“Then also, physicians aren’t really trained to talk to their patients about those issues,” said Matt Eyles, CEO of America’s Health Insurance Plans. “It’s a huge gap that we have. We know lack of nutritious food or very high-calorie, very high-sodium,” are contributing to the prevalence of chronic conditions, but health care is not managing them early enough. All sectors can do better, Eyles argued.
For Grande, America’s food problem is reminiscent of its tobacco problem, a policy issue she worked on. Addressing poor diets will take the same kind of political will and leadership she saw during the tobacco era, and the same adjustment to social cues, like getting rid of ashtrays in public spaces. “Those ashtrays were replaced with candy dishes on conference tables. So here you have the wrong alternative,” she said.
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