BLOG: Cost of chronic disease management limits affordable health care

As the 2016 presidential race heats up, there is much discussion about health care and the effectiveness of the Affordable Health Care Act. While one side continues to talk about repeal, the other side talks about augmenting the act or even replacing in with a single payer system.

There is a good reason for all of this rhetoric. A December Reuters poll found that 62% of Americans surveyed were concerned about the position of presidential candidates on health care affordability.

The Affordable Care Act (ACA) took a bold step in the direction of affordability. Access has been improved for high cost people with the prohibition on preexisting condition exclusions, health status underwriting and renewal requirements for insurers. There is also an increase in affordability for lower income Americans and an expansion of the Medicaid program. The law imposed out-of-pocket limits on in-network cost sharing and ended the annual and lifetime limits on coverage.

In spite of these steps toward affordability, health care in America for many in the middle class and for young families remains unaffordable. This is especially true for the people who consider themselves “healthy” and not in need of medical care. Yet we know that the “unhealthy” once considered themselves to be healthy and did not have the appropriate health education, counseling and preventive care to stay healthy.

Part of the reason that health care in America remains unaffordable is that the cost of care is extremely high. According to CMS data-based estimates, we spend on average of $9,695.00 for every person, every year. Much of that cost is related to the management of chronic medical problems such as diabetes and hypertension and the related dysfunction, disability and rehabilitation. This is, in part, the reason that 1% of the population is responsible for 21% of health care cost and 5% for half, according to the Henry J. Kaiser Foundation.

Much of the energy expended on the implementation of the ACA, as well as the battles to repeal it, have been exerted on the rearranging of the access and the payment of the premiums rather on improving the delivery model to lower the cost.

In the eye care space, we can look at the care required for patients with diabetes to see part of the financial impact. About one-third of patients with diabetes have diabetic retinopathy. The cost to treat these patients with anti VEGF therapy is $7,050.00 per patient per year.

It is well known that primary health care that includes gathering the data to assess health risk, providing health education and implementing preventive action plans is the key to lowering the long-term cost of care. However, the ACA has done little to foster this type of care. Part of the problem is that the current physician-based model for primary care is woefully short of the resources required to execute an aggressive primary health care strategy.

Programs that foster the use of nonphysician health care providers for the delivery of basic primary health care services is the only practical health care delivery model for America. These programs must leverage technology with the use of electronic health records and the use of the direct trust communication system to move critical primary health care data points among all providers involved with the care of each patient.

At the top of the list of nonphysician primary care providers are America’s optometrists. Well distributed around the country, licensed to provide medical care in each state, optometrists see the young “healthy” patients and see them almost every year to manage refractive errors. Optometrists are often the only health care provider to see this population during the time of the highest risk of the development of chronic medical problems before it is too late to implement preventive measures.

Optometry as a profession must move away from the ophthalmology medical practice model and move more into primary health care. Individual optometrists can start that shift in their care philosophy immediately with the following steps:

--implement a qualified electronic medical record system;

--do a better family history looking for diabetes and hypertension;

--add a review of social habits such as smoking to your history;

--collect and review vital signs at each visit;

--review the patient’s medication list, especially looking for drugs that manage diabetes and hypertension;

--discuss side effects of these drugs and other drug options if not taken or ineffective for healthy targets;

--review blood pressure, A1c and fasting blood sugar and discuss the risk of vision loss with end organ damage;

--advise your patient to engage in these discussions with the provider treating the disease and with all of their health care providers; and

--communicate with the patient’s other health care providers and collaborate on better ways to manage the patient.

Better health care for America is not just a political question. It needs to start at the grass roots with all of us involved in primary care. We cannot just sit back and accept the status quo. We can all improve our patient’s long-term outcomes with better teamwork on the front end of health care delivery.

References:

The Henry J. Kaiser Foundation. Concentration of health care spending in the U.S. population, 2010. http://kff.org/health-costs/slide/concentration-of-health-care-spending-in-the-u-s-population-2010/. Posted March 13, 2013. Accessed March 11, 2016.

Reuters. Healthcare costs a top concern for Republican and Democratic voters. Dec. 21, 2015. http://www.reuters.com/article/us-usa-election-healthcare-idUSKBN0U42GU20151221.

Weber A, et al. Retinal Physician. 2014;11(5):41-46.