The Patient Protection and Affordable Care Act, with its numerous references to chronic diseases, case management and care coordination, provides a general framework for improving the care of people with chronic conditions, but it is only a starting point. To build upon PPACA in California, policymakers, legislators, providers and insurers need to address at least five issues.
The number one post-PPACA priority for improving the lives of Californians with chronic conditions is to assure their access to health care. The Congressional Budget Office and the Joint Committee on Taxation estimate that nationally PPACA will leave “23 million nonelderly residents uninsured,” including millions in California, many of whom will have a chronic disease that will not be optimally treated due to their lack of health care access. This is unfortunate, as CalPERS supports health coverage for all Californians.
A second priority is expansion and modernization of health information technology in California.Â This is essential for people with chronic conditions. The provisions in the American Recovery and Reinvestment Act of 2009 regarding “meaningful use” of electronic health records should expand the reach of health IT.Â A recent national survey by the California HealthCare Foundation noted that “those with chronic conditions â¦ are more likely to experience positive effects of having their information accessible online” in a personal health record. More widespread adoption of PHRs and other types of health IT promises to revolutionize chronic disease care. Among other efforts to advance health IT in California, CalPERS recently participated in an e-prescribing pilot project and is currently participating in a project to demonstrate integration of genomic information into an electronic health record system. CalPERS is represented on the board of directors of Cal eConnect, a not-for-profit entity that promotes health information exchange in California.
Third, interested parties must work together for the common good to advance chronic disease care.Â A recent essay by William Sage of the University of Texas in Health Affairs advocates for a “decision to rein in special interests and begin a social conversation about redesigning health care delivery to produce the most cost-effective results,” and that sentiment could be applied specifically to chronic conditions.
Fourth is a need for research to expand the knowledge base for chronic disease management. For example, a bundled payment approach (e.g. as embodied in the PROMETHEUS PaymentÂ® model) is considered to be a “promising” method for reducing health care costs. However, we are unaware of scientific literature examining the approach’s effect on the quality of care for chronic diseases and look forward to such studies.
Finally, interested parties should allow and encourage the translation of scientific studies’ findings into practice. A number of models of care delivery are based on research findings, such as the “Chronic Care Model” developed by Ed Wagner and others and the “Patient-Centered Medical Home” advanced by physician organizations.
Along the lines of these models, Blue Shield of California, Catholic Healthcare West and Hill Physicians are conducting a pilot project involving CalPERS members in the Sacramento area. The pilot involves the alignment of health plan, hospital and medical group incentives to improve cost and quality. Similarly, CalPERS, the Pacific Business Group on Health and Anthem Blue Cross have embarked on an “Ambulatory Intensive Care Unit” pilot project that seeks to improve the quality of care and reduce the cost of care for people with chronic, complex conditions. The results of such projects will help guide future expanded implementation of the models.
Just as high-quality follow-up care is important for good surgical outcomes, intense long-term follow-up work is necessary for California to take advantage of PPACA as it relates to chronic conditions.