Current Issues in Pharmacoeconomics2

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Managed care, outcomes and chronicillness

The high economic costs associated with chronicillnesses, which partly result from inadequate treatmentfor such conditions, make it imperative that managed­care companies 'rise to the challenge o/providing high­quality, cost-effective care' to this patient population,according to Dr Lewis Sandy and Rosemary Gibsonfrom the Robert Wood Johnson Foundation in Princeton,New Jersey, US. l

Because chronic diseases generate high costs,Dr Sandy and MS Gibson suggest that delivery systemsthat optimise the care of patients with such conditions'merit close scrutiny'. Optimal chronic-care deliverysystems include the following:

• integration of primary and secondary care

• integration of medical care with domiciliary- andcommunity-based services

• integration of patient and family perspectives intothe care process

• emphasis on patients' functional status and qualityof life

• delivery of health services in multidisciplinary teams.

Opportunities for managed careCharacteristics of managed-care systems that are

likely to improve care for patients with chronic illnessesare: an ability to intervene at the system, rather than theindividual patient or provider level; capitated financing,which allows healthcare resources to be allocated tobest meet the needs of patients with chronic illnesses;and prepaid financing, which generates an incentiveto provide cost-effective care in the most appropriatesetting. Also, the primary-care orientation of managed­care delivery systems may be more appropriate forcaring for patients with chronic illness, than a secondary­care orientation.

However, managed-care companies may fail toembrace the required level of system development, andtend to focus on common conditions rather than rare,chronic conditions. Also, current quality indicators andaccrediting bodies focus on acute and preventive careservices, rather than chronic care services.

Standard medical care often fails to meet the needsof patients with chronic diseases, even in managed­care environments. According to US-based researchersfrom Group Health Cooperative's Center for HealthStudies and the WA MacColl Institute for HealthcareInnovation in Seattle, Washington, there are 5components of healthcare systems that are likely tolead to a significant improvement in the outcomes of,and costs to, patients with chronic illness [see figure]:2

• evidence-based protocols for managing patients• reorganisation of healthcare practice systems and

provider roles

• improved patient education• timely availability of relevant expertise• more organised and readily available clinical data.

PhannacoEconomics & Ou1Comes News 29 Jun 1996 No. 68

Improving health outcomes in chronic illness

I Evidence-based protocols [

/ ~Practice redesign Infonmation

.. Appointments .. Remind.,.• Roles .. Outcome•• Follow-up .. Feedback

.. Care planning

Patient education Expert systems.. Self-managament .. Provider educalion.. Behaviour change • Decision .upport.. Plychological suppor1 .. Consultation•.. Patient participation

If managed-care plans cannot improve quality,contain costs and add value to the care of patients withchronic illnesses, US society may reconsider whethermarket-oriented managed care should be a frameworkfor healthcare in that country, warn Dr Sandy andMs Gibson.!

1. Sandy LG, et aI. Managed care and chronic care: challenges andopportunities. Managed Care Quarterly 4: 5-11. No.2, 1996 2. Wagner EH,et al. Improving outcomes in chronic illness. Managed Care Quarterly 4: 12-25,No. 2, 1996 800<31196

1173-5503196/0068-00021$01.00°Adi. International Limited 1996. All right. rnerved