People with chronic health problems are heaviest users of medical care, but system not organized to meet their needs

December 14, 2001

The heaviest users of the medical care system are the 128 million Americans who suffer from chronic health conditions, disabilities, or functional limitations. However, the system is not organized to meet their needs, according to a study conducted by the Johns Hopkins Bloomberg School of Public Health. People with more than one chronic condition, disability, or functional limitation have even greater difficulty receiving appropriate care. The study, which appears in the November/December 2001 issue of Health Affairs, suggests that better education of clinicians and changes in eligibility rules and health insurance coverage policies are needed to provide a system geared to the care for people with chronic health problems.

"Our health care system is oriented towards treating people with acute episodes, and not people with recurring problems or long-term health needs," says Gerard Anderson, PhD, professor of health policy and management and international health at the Johns Hopkins Bloomberg School of Public Health and national program director for Partnership for Solutions, an initiative to improve the care and quality of life of Americans with chronic health conditions.

"Millions of Americans suffering from chronic health problems, disabilities, or functional limitations must navigate a complex system of doctors, specialists, and caregivers with little help or coordination of care. Fundamental changes are necessary to design a health care system to meet the needs of those who use and need it the most," explains Dr. Anderson.

Using the Medical Expenditure Panel Survey (MEPS), Dr. Anderson and James Knickman, PhD, vice president for research and evaluation at the Robert Wood Johnson Foundation, estimated the number of Americans in 1996 suffering from long-term health problems and divided them into three categories; chronic problems, functional limitations,and disabilities. The researchers determined that 120 million Americans currently suffer from chronic health conditions, such as diabetes, heart disease, depression, and arthritis. They are also responsible for 75 percent of all medical care spending. Approximately 39 million Americans suffer from disabilities, which include physical impairments, as well as mental illness and drug addiction. Nearly 12 million suffer from functional limitations. People with functional limitations require special medical or supportive services, which can include home nursing or program like Meals-On-Wheels, to carry out daily activities.

Many people have more than one condition or overlapping conditions. More than 9.5 million Americans have all three conditions and have medical costs that are 16 times greater than people without any chronic conditions. They are also 10 times more likely to be hospitalized and 5 times more likely to see a doctor or need prescription drugs.

"Many people with chronic health problems will see as many as eight different doctors in a year, but most health care information systems do not allow doctors to know what care others are providing for their patients. Some care is deemed a "medical expense" while other services, like home nursing care, may be considered a "social expense" and may not be covered or will be covered under a different program with different rules. In other cases with an injury, long-term care may only offered for a limited time, even when some individuals may need longer treatment," explains Dr. Anderson.

Dr. Anderson adds that long-term care coverage is often based on financial needs. Ironically, the most complete long-term care and services are often available only to the poorest people. According to the study, this disparity can severely limit the treatment options available to physicians and create large out-of-pocket expenses for patients.

Dr. Anderson also says changes are needed in the clinical culture and in medical school curriculums to make coordination of care more feasible. Currently, doctors and nurses are trained in hospitals where they handle acute cases and the "appointment of the day." While this strengthens diagnostic skills, it does not provide training for coordinating care for long-term conditions. Insurance companies should also compensate doctors and other caregivers for the time they spend coordinating care for patients, instead of only paying the single office visit.

"Care for chronic conditions is the number one reason people seek medical attention. The current system is not working for 40 percent of the population. Policy makers need to take the lead to create a health care system that integrates financing and care delivery," says Dr. Anderson.
The study was funded by Partnerships for Solutions and the Robert Wood Johnson Foundation.

Johns Hopkins University Bloomberg School of Public Health

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