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The American Journal of Accountable Care September 2019
Achieving a Culture of Health: Steps for Engaging State Government
Dennis P. Scanlon, PhD; Jocelyn M. Vanderbrink, MHA; Mark Sciegaj, PhD; and Brigitt Leitzell, MS
Implementation Variation in Natural Experiments of State Health Policy Initiatives
Diane R. Rittenhouse, MD, MPH; Aryn Z. Phillips, MS; Salma Bibi, MPH; and Hector P. Rodriguez, PhD, MPH
Current Value-Based Care Models Need Greater Emphasis on Specialty Care
David Roer, MD; Mayumi Fukui, MBA; Natalie Smith, MSPH; Allen R. Nissenson, MD; and Bryan N. Becker, MD
Building Trust Can Improve American Healthcare
Richard J. Baron, MD, President and Chief Executive Officer, American Board of Internal Medicine and the ABIM Foundation
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The Case for Decoupling Chronic Disease Care From Insurance and Restructuring How We Pay for It
Jackson Williams, JD

The Case for Decoupling Chronic Disease Care From Insurance and Restructuring How We Pay for It

Jackson Williams, JD
For many Americans, chronic care is not integrated or effectively managed by insurers. Another entity should be designated to bundle this care inexpensively.

Berwick and colleagues’ vision of the Triple Aim foresaw achievement of its goals through assigning responsibility for a population to an “integrator.” It was thought that an insurer would be best situated for this role, but with 45% of those aged 19 to 64 years either uninsured or underinsured, a significant portion of chronic disease care is not paid for by insurers. This article proposes that chronic disease care amenable to streamlining and inexpensive pricing be decoupled from the insurance system, with designation of an alternative integrator to administer a Registry+Bundle. This integrator would acquire and distribute, at a low cost, the medications necessary to manage a disease for a given population.

The American Journal of Accountable Care. 2019;7(3):26-29
In an influential 2008 Health Affairs article, Donald Berwick, MD, MPP, FACP, and colleagues introduced the Triple Aim: “improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.”1 In their vision, these goals would be achieved by recognizing “a population as the unit of concern” and assigning responsibility for that population to “an ‘integrator’ able to focus and coordinate services to help the population on all three dimensions at once.”

Ideally, Berwick et al said, that integrator would be an entity “such as Kaiser Permanente, [that] has fully integrated financing and either full ownership of or exclusive relationships with delivery structures, and…is able to use those structures to good advantage,” but the “role might [also] be within the reach of a powerful, visionary insurer; a large primary care group in partnership with payers; or even a hospital, with some affiliated physician group.”

As CMS administrator, Berwick presided over accountable care organizations and other payment models that applied the Triple Aim to Medicare beneficiaries. In their 2008 article, Berwick et al used the example of congestive heart failure (CHF) as a chronic illness as one upon which “an integrator would act differently, assigning much more value and many more resources, for example, to the monitoring and interception of early signs of deterioration.” Remarkably, the rate of hospital admissions for CHF among the Medicare population has dropped from 2222 per 100,000 in 2001 to 1364 in 2015.2

But the picture is much different for diabetes, a condition afflicting many Americans not eligible for Medicare. Hospital admissions for short-term complications in the adult population have increased, most notably in the group aged 18 to 64 years: from 52.6 per 100,000 in 2000 to 92.3 in 2015.2 Hospital admissions for long-term complications of diabetes among those aged 18 to 64 years increased from 78.3 per 100,000 in 2000 to 92.0 in 2015, while dropping significantly in the Medicare population.2 The pattern is similar for amputations and end-stage renal disease incidence: improvements in the Medicare age group but flat or worsening numbers for the nonelderly population, with negligible improvements or backsliding in the first 2 years of coverage under the Affordable Care Act (ACA).

The premise of this article is that a significant portion of the disparity between advances in CHF care and retrogression in diabetes care can be attributed to differences in insurance coverage between the elderly and nonelderly populations. Americans 65 years and older are covered by Medicare. About one-third of Medicare beneficiaries are enrolled in managed care plans, and of those in fee-for-service Medicare, only 19% lack supplemental coverage to cover cost sharing.3 Only 12% lack prescription drug coverage.4 Nearly one-third of beneficiaries enrolled in Part D prescription drug plans receive low-income subsidies that reduce cost sharing, and half of Part D plans offer coverage before the $415 deductible is met. In short, conditions are favorable, if not quite ideal, for the management of chronic conditions.

The situation is different for the nonelderly population. Of adults younger than 65 years, 12.4% remain uninsured, but in the judgment of The Commonwealth Fund, fully 45% of those aged 19 to 64 years are “inadequately insured.”5 The Commonwealth Fund counts as underinsured those whose out-of-pocket costs equal 10% or more of household income, individuals living under 200% of the federal poverty level (FPL) whose out-of-pocket costs equal 5% or more of household income, or those whose insurance deductible is 5% or more of household income.

The Commonwealth Fund finds that “more people who have coverage are underinsured now than in 2010, with the greatest increase occurring among those in employer plans.” According to the Kaiser Family Foundation 2018 Employer Health Benefits Survey, “Over the past five years, the average annual deductible among all covered workers has increased 53%. Forty-two percent of covered workers in small firms and 20% of covered workers in large firms are in a plan with a deductible of at least $2000 for single coverage.”6

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