A Gap in Quality to Care Coordination for Individuals With Chronic Illnesses

Introduction

The health care system is mostly built on the basis of acute episodic care that does not correlate with the needs of patients with chronic diseases. Long-term illnesses are often left uncured or insufficiently treated until severe complications occur. Despite the fact that a chronic condition is diagnosed, there is often a considerable gap between evidence-based treatment recommendations and actual practice. Concerning the specific population affected by the inequality, advances in medicine prolong life expectancy, although not entirely curing patients’ diseases. However, this has directed to a rise in the number of individuals having chronic illnesses.

The proportion of older people is rising, resulting in the growing quantity of people with chronic health problems due to the cumulative impact of risk factors throughout life. Moreover, the amount of young and middle-aged people with various lifelong health diseases is expanding. The most recent data from the United States indicate a rapid increase in the number of children and adolescents with chronic conditions since the 1960s, primarily due to rising obesity rates (Raghupathi & Raghupathi, 2018). The upsurge in the prevalence of long-term diseases among children suggests a subsequent increase among the majority of adults’ related diseases (Raghupathi & Raghupathi, 2018). Consequently, population aging is significant, but it is not the only factor in the growing chronic disease.

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The gap-related to persistent illnesses has been addressed since the end of the 20th century. Firstly, as a concept, disease management was first mentioned in the United States in the 1980s (Daaleman & Helton, 2018). It was initially used primarily by pharmaceutical companies that offered training programs to employers and managed care organizations to promote adherence and lifestyle changes for chronic conditions such as diabetes, asthma, and coronary artery disease (Daaleman & Helton, 2018).

Since the mid-1990s, disease management strategies have become more widespread in the U.S. healthcare industry (Daaleman & Helton, 2018). By 1999, about 200 companies offered programs for controlling illnesses such as diabetes mellitus, bronchial asthma, and heart failure (Daaleman & Helton, 2018). At the same time, health insurers, medical groups, and clinics also increasingly offered their disease management programs (Daaleman & Helton, 2018).

Impact of the Population Socioeconomic Background

People with insufficient income often lack access to health care or preventive measures; consequently, it leads to bad health outcomes and worsening chronic conditions. Providing health care to the low-income segment of society is often limited or impeded by costs. In general, preventive treatment is much more expensive and often out of reach for the poor, resulting in avoidable health problems becoming chronic (Reynolds et al., 2018).

The costs of treating long-term illnesses can be conditional when the diseases are not initially treated or appropriately prevented. For example, direct costs of treating chronic mental disorders might be $42.5 billion per year (Reynolds et al., 2018). The proportion of Americans covered by health insurance has declined steadily since the mid-1990s (Daaleman & Helton, 2018). This means that millions of people lived at least part of the year without insurance and confidence in the future.

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Effect on the Healthcare Delivered and Potential Implications

Healthcare has generally focused on a relatively small population with high needs, overlooking the necessities of most people with chronic illness and disabilities. Daaleman and Helton (2018) suggest that there is a direct link between public health and economic prosperity. While the population’s health is improving, it contributes to economic growth, which should have implications for policy development (Daaleman & Helton, 2018).

For instance, national and international organizations interested in economic development need to consider investing in public health in achieving this goal seriously (Daaleman & Helton, 2018). Chronic illness is a severe obstacle for the economy; in the United States, it is estimated that the cost of treating chronic diseases is about three-quarters of total health care spending (Daaleman & Helton, 2018). Considering people’s well-being as an element of human capital, health deterioration entails additional expenditures at the macroeconomy and individual levels.

Chronic cases such as heart disease, diabetes, cancer, respiratory illnesses, and stroke are the principal factors of death globally – they cause 60% of all deaths (Holman, 2020). Long-term conditions annually extinguish millions of lives, result in severe complications associated with disability and the need for high-cost treatment. The direct cost of heart care is about $500 per person annually (Holman, 2020). Indirect costs, including lost workdays and lost productivity, deducted from family income are $3 thousand per year (Holman, 2020). Assuming all these people could work, the annual productivity loss is approximately $6 billion (Holman, 2020).

In modern times, the healthcare system is faced with extending the period of active life, improving its quality, and maintaining the ability to work with patients with these diseases. Losses from the population’s declining health at the country’s economic level could be the underproduction, decreased labor productivity due to illness, disability, and high mortality among economically active citizens.

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Existing Initiatives

Existing Healthcare Initiatives

The growing prevalence of chronic diseases poses additional challenges to the health system. Chronic illness requires complex care models that need collaboration between workers from different professions and institutions that have traditionally operated separately. Disease management initiatives are now widely used by funding companies in the United States. These include the U.S. federal government, which has conducted a voluntary Medicare Chronic Care Improvement Program for people over 65 (Raghupathi & Raghupathi, 2018). The program is targeted at different populations of patients with heart failure or diabetes being implemented by private disease management organizations (Raghupathi & Raghupathi, 2018).

Several states have performed Medicaid disease management programs (Daaleman & Helton, 2018); more than half of the states have some form of Medicaid disease management (Daaleman & Helton, 2018). In 2005, two-thirds of employers in companies with 200 or more workers included disease management in their employee health insurance plans (Daaleman & Helton, 2018). However, such programs’ type and scope vary widely, from small initiatives involving some patient groups to large-scale programs targeting practically all chronic illnesses of different payers.

Medicaid health insurance has been protecting the rights of the poor since 1965. To be accepted into this program, a person needs to collect documents confirming a low income and fill out numerous papers (Teno et al., 2018). The system provides medical care for large families and disabled people (Teno et al., 2018). Medicaid services include physicians’ consultations, hospital stays, vaccinations, drug prescription, and preventive care for children.

Another significant service delivery model is the Evercare, developed in the late 1980s in the United States, primarily to meet high-risk patients’ needs. It was realized in the late 1980s by the UnitedHealth Group commercial health insurance program for the Minnesota state administration (Daaleman & Helton, 2018). Its principal purpose is to combine prevention and treatment for patients at high risk of ill health. The Evercare model is a form of disease management that was initially targeted at older adults with a low state of health and increased risk of unplanned hospitalization (Daaleman & Helton, 2018).

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The program uses methods for identifying risk groups, making it possible to assess the required level of care, develop an individual treatment plan, and coordinate and monitor by a specialist nurse as the patient’s curator (Daaleman & Helton, 2018). Later, the program also covered older people living at home.

Specific Goals

With regard to the Medicare program, its central goal is to protect patients from socially vulnerable groups. This has considerably helped millions of adults to receive the treatment and care they need (Teno et al., 2018). It also improved the lives of young Americans with disabilities as it enabled them to get the treatment they required through Medicare. Evercare’s approach to patient management has reduced care costs for elderly patients in nursing homes in the United States (Daaleman & Helton, 2018). This was achieved by reducing the consumption of health services such as hospital admissions and emergency care.

Circumstances and Funding

The reason for the development of the existing initiative is the fact that many U.S. citizens are left without health insurance due to financial problems or serious illnesses that existed even before applying for insurance. These are the so-called pre-existing conditions; reconsideration of the healthcare system is also caused by the awareness that a comprehensive list of factors influences health (Holman, 2020).

For example, there are differences in individuals’ sensitivity and resilience to chronic disease (Holman, 2020). The developing incidence of causal health impairments raises questions about whether the health system can manage chronic illness in the long-term perspective when fighting through standard methods (Holman, 2020). The American government provides most funds; the Medicare program is financed by a portion of workers’ and employers’ payroll tax. It is also subsidized partially by monthly contributions deducted from the social security administration.

Intention Weaknesses

Existing initiatives cannot be considered perfect; for instance, Medicare’s negative outcome is the amount of money that should be administered. This sum comes to about 15% of the total U.S. budget and is growing annually (Holman, 2020). The country’s budget is reviewed according to the expenditures. The health care system takes money away from other vital projects such as the fight against poverty and education, which can also significantly impact society. Some aspects need to be changed to provide a more efficient and streamlined process to lower costs and speed up medical service.

Moreover, Medicare needs to address many other different issues, such as hospitals’ costs. The most prominent subject that should be answered is the best and most effective way to provide every American with good health care. Pharmaceutical companies use patient law to monopolize the market, which increases the amount that everyone has to pay (Teno et al., 2018). Actions need to be taken to reduce medical care costs and provide a more efficient administration process.

Regulation

Concerning regulation, Barack Obama’s law approved the reform of the health care system in the United States. The Affordable Care Act (ACA), or Obamacare, was signed into law in March 2010 by President Barack Obama (Daaleman & Helton, 2018). The former president made significant changes to the U.S. medical system between 2011 and 2014 (Daaleman & Helton, 2018). The regulation is important as the provisions included in health care and patient protection reform aimed to increase access to health care focus on disease prevention.

The regulation is being addressed at multiple levels. The Medicaid program has expanded significantly; however, in 2012, the Supreme Court ruled that the states should make independent decisions (Daaleman & Helton, 2018). By November 2015, 30 states had agreed to expand the program, thereby providing insurance to more of the population (Daaleman & Helton, 2018). Meanwhile, in 20 states that did not expand Medicaid, an estimated 3 million low-income adults faced insurance inequality when their incomes exceed current Medicaid benefits but are not high enough to purchase private insurance (Daaleman & Helton, 2018).

It is legally specified that any health insurance must cover services in ten main categories: outpatient services, emergency medical services, hospitalization, care for pregnant women and newborns, psychiatric services, prescription drugs, rehabilitation services, laboratory services, preventive and wellness assistance, pediatric aid, including dentistry and ophthalmology (Raghupathi & Raghupathi, 2018). Each state autonomously defines the range and scope of specific services covered by each category (Raghupathi & Raghupathi, 2018). The law authorized a ban on a refusal by insurance companies to provide services to those who had a disease before purchasing an insurance policy.

In October 2017, President Donald Trump signed a declaration canceling several of Obama’s reform provisions. It could help people preserve millions of dollars, while Obamacare is costly reform for the U.S. budget. The new measures allow institutions to purchase insurance from private companies, whereas the latter can provide short-term health coverage (Raghupathi & Raghupathi, 2018). The list of services included in them is more limited, but, according to the plan, they should also require fewer funds. Thus, Americans are given more health insurance choices so that they can find insurance policies that suit their needs. However, it should be noted that in this case, not every individual citizen will have access to quality health care.

Conclusion

The medical system’s concentration is mostly focused on urgent and measurable issues, for example, outbreaks of infectious diseases or the reduction of hospital queues. Despite their massive contribution to the overall situation, chronic diseases are not seen as an instant or easily measurable issue. Due to the economic crises and the resulting increase in unemployment, more citizens began to apply for state insurance for the poor. These days, public insurance programs cover more than a third of the U.S. population and are responsible for nearly half of the country’s health care costs. This insurance covers predominantly vulnerable people who are unable to purchase private insurance.

A solution that can be a critical point of reducing health care costs, including Medicare, is to increase life expectancy and cure patients from age-related ailments – cancer, cardiovascular disease, diabetes, and Alzheimer’s disease – that is, prolonging an overall life expectancy. Such changes will be a critical factor in maintaining America’s financial viability. Moreover, some tendencies define the intention’s necessity. There are opportunities to prevent illnesses in the early stages. New capacities increase awareness of disease reduction benefits to diminish financial pressures on health systems and balance treatment and prevention.

However, the main issue is not moving resources from treatment to prevention. It concerns finding ways to integrate these areas so that prevention programs can take full advantage of the fight against the gap in quality related to care coordination for those who have chronic illnesses. Growing social inequality changes the balance between services that respond to demand and proactive services that identify needs. For some patients with chronic diseases whose needs are most significant, the help required may be the least available.

References

Daaleman, T. P., & Helton, M. R. (2018). Chronic illness care: Principles and practice. Springer.

Holman, H. R. (2020). The relation of the chronic disease epidemic to the healthcare crisis. ACR Open Rheumatology, 2(3), 167−173. Web.

Raghupathi, W., & Raghupathi, V. (2018). An empirical study of chronic diseases in the United States: A visual analytics approach to public health. International Journal of Environmental Research and Public Health, 15(3), 431. Web.

Reynolds, R., Dennis, S., Hasan, I., Slewa, J., Chen, W., Tian, D., Bobba, S., & Zwar, N. (2018). A systematic review of chronic disease management interventions in primary care. BMC Family Practice, 19(1), 11. Web.

Teno, J. M., Gozalo, P., Trivedi, A. N., Bunker, J., Lima, J., Ogarek, J., & Mor, V. (2018). Site of death, place of care, and health care transitions among U.S. Medicare beneficiaries, 2000-2015. JAMA, 320(3), 264−271. Web.

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AssignZen. "A Gap in Quality to Care Coordination for Individuals With Chronic Illnesses." July 28, 2022. https://assignzen.com/a-gap-in-quality-to-care-coordination-for-individuals-with-chronic-illnesses/.

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AssignZen. 2022. "A Gap in Quality to Care Coordination for Individuals With Chronic Illnesses." July 28, 2022. https://assignzen.com/a-gap-in-quality-to-care-coordination-for-individuals-with-chronic-illnesses/.

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