| TESTIMONY
Presented
to the
UNITED
STATES HOUSE OF REPRESENTATIVES
COMMITTEE ON WAYS AND MEANS
HEALTH SUBCOMMITTEE
Hearing
on Medicare Chronic Care Improvement Program
Tuesday
May 11, 2004
Presented
by
Janet S. Wright, MD, FACC
On
behalf of the
American College of Cardiology
For
more information contact the American College of Cardiology
at (800) 435-9203
Chairman
Johnson and members of the subcommittee:
I
am here today as a practicing cardiologist and a Fellow of
the American College of Cardiology, (ACC) an organization
whose mission is to advocate for quality cardiovascular care-through
education, research promotion, development and application
of standards and guidelines-and to influence health care policy.
My comments reflect the policy position of the College, although
I could not presume to represent the diverse opinions of the
over 30,000 members of the ACC. I do however, represent the
interests of my patients and on their behalf, I express my
gratitude for the efforts you make on a daily basis to improve
health care in America. I believe that your contributions
will initiate an historic improvement in the quality of health
care for Medicare beneficiaries.
Any
policy maker, health care professional or sick person in America
knows that our health care system is broken. Our striking
success in combating life-threatening illnesses has extended
the lives of millions of Americans, and in that victory, converted
acute events into chronic conditions. Our older citizens suffer
multiple diseases, visit an average of seven doctors a year,
and take more than twice that many medications each day. These
patients need near-constant oversight and continuous care
coordination to stabilize their conditions and to avoid the
episodic, usually urgent and costly rescue from a preventable
deterioration.
As
seniors’ complex medical conditions multiply, the physician
workforce is shrinking due to unmet needs for job satisfaction,
adequate reimbursement, and liability protection, among other
factors. Quality medical care takes time and resources to
deliver and good doctors are struggling these days to care
for the burgeoning chronic disease population. The therapeutic
alchemy of the patient-physician relationship disintegrates
under the pressures of today’s fragmented care interaction.
When the personal connection breaks down between patient and
doctor, so does adherence to advice, trust, satisfaction,
and inevitably, the clinical outcome. To deliver excellent
care, physicians need additional resources to provide patient
and family education, to track practice adherence to established
guidelines, and to supply our statistics to a variety of “measurers”
in the health care arena. To practice 21st century medicine,
practitioners must have current, complete, and accurate data.
Those data, and the resources for gathering them, are absent
in most medical practices today.
Advances
in science, funded robustly by this Congress, have been translated
into evidence- or guideline-based medicine, setting the standards
of care and shaping medical decision-making. Yet few doctors
can afford the information technology or human resources to
bring these recommendations to the point of care delivery,
much less to record, track, and report their performance,
an increasingly common requirement in the medical marketplace.
Despite best efforts of well-trained and dedicated physicians,
our own measures of quality have demonstrated dispiriting
gaps in care. Health care has metamorphosed; health care delivery
systems have not.
Although
I do not know the solutions to our complex health care crisis,
I can list the basic characteristics of those solutions. Collaboration
is critical as the problems are clearly insurmountable by
any single organization or entity. Improvements will be incremental
or staged because the distance we must travel from our present
state to a significantly better one is staggering. Evidence
or guideline-based medicine is the accepted standard,
and a steady focus on quality, with all the
attendant difficulties, will help guide us to a better system
of care. The solution must be comprehensive,
in the sense that quality care is to be delivered in all settings,
for all conditions. Finally, and most importantly, the new
system will be marked by enhanced communication
on the macro level by adaptable IT and appropriate infrastructure,
and on a personal level by a resuscitated patient-physician
relationship.
The
approach known formally as disease management has grown exponentially
in the current chaos because it provides among other things,
vital systematic links among participants in the health care
system. Emphasis on populations, self-care instruction, and
continuous cross-talk between patients and the care team mark
a few of the unique features of the disease management approach
that are missing in the traditional care model. Disease management
harnesses information technology and other important tools
to assist with application of evidence-based medicine, data
collection and analysis, patient and physician adherence,
and performance enhancement. Disease management brings constructive
additions to current health practices and holds promise for
improvements in care delivery.
As
an example of highly effective disease management, I call
your attention to a mature and profoundly valuable program
which has provided education in self-management and health
preservation, linked patients and doctors through frequent
progress reports, and not just satisfied, but indeed, life-changed
its participants. That program is one of the original disease
management approaches known as Cardiac Rehabilitation. The
design has from its inception been multidisciplinary, bringing
together cardiac nurses, exercise physiologists, dieticians,
and cardiologists with expertise in disease prevention and
health promotion. These sophisticated programs begin with
detailed intake interviews, identifying not only the medical
conditions which require monitoring and management, but also
the social and psychological hurdles to achieving and maintaining
good health. The structured weekly sessions provide the continuous
and repetitive feedback proven to effect changes in behavior.
The care team members support these gradual, key behavioral
shifts, become trusted sources of information, and most importantly,
serve as community-extended radar, detecting early signs of
decompensation, medication errors or poor adherence, and new
or recurrent disease states.
Patients
undergoing cardiac rehabilitation “graduate” armed
with knowledge of their disease process, their prognosis,
and their limitations; the latter most certainly reduced by
the personalized protocol of exercise, nutritional counseling,
stress-reduction training, and medical supervision. In these
days of “drive-by” open heart surgery and two-day
admissions for heart attacks, the educational process is so
critical for the restoration of physical and mental health
and improved functional status takes place in one and only
one place: Cardiac Rehabilitation. Even with the fiscally
constrained reach of cardiac rehabilitation programs, the
disease management principles have succeeded in improving
the outcomes and outlook for patients with cardiac disease.
The
Voluntary Chronic Care Improvement Programs will incorporate
many features present in the CR/DM model, features which are
fundamental to solving our health care crisis. This unique
design calls for collaboration among the system experts (DM),
the medical pros (physicians and health care team), and the
payers in a mutually rewarding arrangement for the benefit
of patients with congestive heart failure, complex diabetes,
and chronic obstructive pulmonary disease. The successful
models/components will be identified in a three-year process
and made available to the appropriate Medicare population
in a staged fashion. Outcome measures of quality and satisfaction
will be selected in advance, monitored, and reported, highlighting
the use of information technology and reinforcing the practice
of guideline-based medicine.
Even
though there are specific targeted diseases in the Phase I
programs, the approach is most appropriately comprehensive
in the attention given to co-morbid conditions and overall
health status. This is both complicating for the program administrators
and absolutely necessary for the applicability of these approaches
to real-life medical care of aged and disabled Americans.
Cost data will be important, but not sole determinants of
program success. Although typically unprofitable for hospitals,
cardiac rehabilitation programs achieve striking gains in
quality of life, patient satisfaction, and clinical outcomes.
Phase I programs that predominantly emphasize well-established
clinical outcomes are in the patients’ and ultimately,
the country’s best interest. In fact, the very foundation
of a disease management strategy is that early and frequent
intervention ( whether education, medication adjustment, further
evaluation, and/or alteration in treatments) improves the
patient’s ability to function at the highest level possible.
I strongly encourage selection of programs that focus on quality
improvement, as those are most likely to result in concomitant
enhancements in beneficiary and provider satisfaction. Finally,
I trust that the programs selected for Phase I will recognize
the therapeutic value of a healthy patient-physician relationship
and will support fluid communication among members of the
care team, family members, and caregivers.
In
Section 721 of the Medicare Prescription Drug, Improvement,
and Modernization Act (MMA) of 2003, Congress has broken new
ground in health care delivery design. Many aspects of the
MMA are revolutionary in the transformation of health care
in the United States. New partnerships will be formed, innovative
approaches will be tested, and the underlying audacious concept
is that quality medical care will lead to better financial,
satisfaction, and clinical outcomes.
That
said, I believe that the greatest achievements of this legislation
will be realized in an evolutionary way. Section 721 sets
in motion a new direction in health care which will find expression
in ways we cannot anticipate. We will learn from the experience
of Phase I, and future innovators and disseminators will adapt
the processes as populations and medical conditions mandate.
I expect to discover through the Phase I project, the techniques
and processes that work and those that need further modification
or perhaps application in a different subset of patients.
Learning where and how and in whom to apply these principles
of care will be an invaluable lesson. I anticipate that practices,
health plans, and other care delivery systems which are not
part of the Phase I projects will follow the progress reports
closely and begin to implement the winning strategies. The
goal is to improve the quality of care for all, to close the
gaps that still exist, and to do so in a cost effective manner
which will enable us to provide care to all in need. It is
my hope that as much meticulous care and concern go into these
future designs as was invested in the crafting of this legislation
and in its implementation.
I
encourage physicians to investigate the Chronic Care Improvement
Programs, to consider the potential benefits to their patients
and their practices, and to participate however possible so
that the ultimate delivery model reflects what we know to
be true: compassionate individualized care is effective, essential,
and rewarding. We will always treat one human being at a time
and, in that moment, serve the larger population well. The
opportunity now presents to combine this best practice of
the healing arts with a high tech, population-based approach,
a challenge which calls for the integrity and commitment of
the brightest minds in health policy, system design, and medicine.
In
closing, I share a physician’s wish list for the future
perfect state of medical care. Many of these wishes could
come true in the Phase I and II programs and they are essential
components of a fit and functional health care system.
- I
want to be on the design team for the process of care. (Physician
involvement)
- I
want to know my “score,” how it is calculated,
and to whom it is reported (Quality/performance measurement)
- I
want my patients to have ready access to a team of experts
in my practice and community who can extend health care
beyond our office visit. (Team care, primary and secondary
prevention)
- I
want current, accurate, complete data available when I need
it so that I can incorporate it into my practice. (Information
technology)
- I
want my patients to have validated, self-care advice when
they need and so they can use it. (Patient education, prevention,
information technology)
- I
must have the ability to afford to deliver this care. (Adequate
reimbursement for a chronic care management system)
I
deeply appreciate the efforts of this subcommittee in improving
our health care system. Your dedication and commitment challenge
all participants in health care to contribute our best to
achieve creative and cooperative solutions. |
