Uncomfortable Truths — What Covid-19 Has Revealed about Chronic-Disease Care in America | NEJM - nejm.org

“Jump off the cliff and figure it out on the way down. People think that improvisation is moving forward,” comedian Keegan-Michael Key has said about improvisational comedy. “What improvisation really is, it’s walking backward.…It’s backing up that gives you discovery.…You back up, you can create a larger worldview.”

The Covid-19 pandemic forced the medical field to jump off the cliff and figure it out. It caused rare disruptive innovation by removing previously impenetrable organizational and political roadblocks. Covid-19 also made us walk backward and see the larger worldview, in the process revealing uncomfortable truths about the U.S. health care system — including our approach to managing chronic diseases. Policy discussions surrounding telehealth coverage and scope of practice for nonphysician health professionals have narrowly focused on fee-for-service reimbursement and haven’t addressed the fundamental problem with chronic-disease care: the system doesn’t support optimal patient health and experience, especially for marginalized populations.

Over the past 2 years, the health care system changed — at least transiently — when it shifted to caring for patients with Covid-19 and preventing virus transmission.¹ Routine in-person visits for chronic diseases plummeted, and telehealth visits skyrocketed. Payers permitted, and increased reimbursement for, telehealth visits. States expanded scopes of practice for nonphysician practitioners, although pushback is now occurring. Lucrative elective procedures, such as joint replacement, were postponed.

At the same time, hospitalizations for chronic conditions unrelated to Covid-19 and for emergencies such as appendicitis decreased. Mortality from dementia, cardiovascular disease, and diabetes increased; it’s unclear whether these trends reflected true increases or undercoding of Covid-related deaths. Rates of low-density lipoprotein cholesterol screening and glycated hemoglobin testing fell, as did new prescriptions for statins and metformin. Marginalized populations had disproportionately high morbidity from Covid-19, and survival rates were lower in underresourced hospitals in low-income neighborhoods than in well-resourced facilities. Addressing social determinants of health proved to be particularly important for good outcomes.

Bill Parcells, a coach famous for turning around bad football teams, once said, “You are what your record says you are.” When it comes to managing chronic diseases such as hypertension and diabetes, the U.S. health care system’s performance is inadequate. Our outcomes reflect what the system rewards.

In football, quarterbacks and wide receivers get the glory for scoring touchdowns, but the battle is won in the trenches by the meat-and-potatoes linemen. Smart football teams invest in their lines. In health care, the glory and financial rewards go to surgeries and other procedures, devices, and medications and to the providers, health care delivery organizations, and companies responsible for these interventions. But the poorly reimbursed trench battles of chronic-disease management, which involve monitoring, coaching on self-management and behavior change, and mitigation of social needs, are critical for the vast majority of time that patients spend outside the clinic in their homes, communities, and workplaces.² The U.S. health care system undervalues human relationships, connections, and longitudinal primary care, so it’s unsurprising that it falls short in this area. Technology and human capital will need to be integrated if we are going to deliver high-quality, patient-centered care.³

Covid-19 has taught us important lessons that apply to chronic-disease care. First, our health care system excels at perpetuating its basic structure and supporting the powerful stakeholders who profit from this structure. We should, therefore, design chronic-disease systems to better support the health and experience of patients and the well-being of health professionals trying to meet patient needs (see box). Payment for telehealth should support and provide incentives for integrated, holistic in-person and virtual care, and it should be administered using value-based models, rather than fee-for-service structures.⁴ We could create teams that assess, treat, and monitor patients, relying on the principles of effective, longitudinal primary care.² We should also coach patients in self-management and behavior change and partner with communities to address social and structural factors impeding good health. Determining the ideal ratio of in-person visits to virtual visits, use of remote-device monitoring, and mix of health professionals will be important.³

Key Components of Chronic-Disease Care and Strategies That Have Been Reinforced by Lessons from the Covid-19 Pandemic.^*

Support for health of diverse patients and communities

Prevention of chronic disease, promotion of health, and care for patients with chronic disease using primary care teams, with access to specialty services as needed

• Provide team-based care spanning home, community, outpatient, and inpatient settings.

  • Individualize type and intensity of services and culturally tailor them to patients’ needs.

  • Shift more care from outpatient and inpatient settings to home and community settings.

  • Provide convenient access to diagnostic and therapeutic services.

  • Provide convenient access to 24-hour care.

  • Allow team members to practice at the top of their licenses.

  • Employ a diverse workforce that reflects the community.

  • Employ community health workers.

• Build strong partnerships with patients to address holistic issues and practical management.

  • Provide coaching and assistance with self-management and behavior change.

  • Engage in close monitoring and follow-up.

  • Address patients’ mental health needs.

  • Address patients’ social needs.

Fulfillment of system-level health and social needs

Integration of human touch, relationships, and the convenience of technology

• Provide an appropriate mix of in-person visits, video or telehealth visits, and remote monitoring.

  • Use video or telehealth to improve access, convenience, timeliness, monitoring, and cost-effectiveness.

  • Use video or telehealth to improve access to emergency care and specialty services in rural and medically underserved areas.

• Design electronic health records to serve patients and clinicians.

  • Integrate social needs screening.

  • Integrate referrals to community-based organizations for social, self-care, caregiving, and disease self-management services, with follow-up feedback information loops as appropriate.

Flexible payment mechanisms that support advancement of population health and health equity

• Provide flexible, up-front funding for chronic-disease care infrastructure, possibly involving capitation, per-member per-month payments, or bundled payments.

• Tie retrospective payment to process and outcome measures that support patient-centered care and health equity.

  • Implement evidence-based clinical performance measures, patient-experience measures, and population and community health measures that reward strong performance for all patients.

  • Reward the reduction of disparities among groups.

  • Reward strong performance and improvements in performance measures for less advantaged groups.

• Align public and private payers’ performance metrics to drive transformation and reduce providers’ administrative burdens.

• Level the playing field for reimbursing components of chronic-disease care.

• Provide adequate resources to safety-net clinics and hospitals.

* Recommendations are adapted in part from the National Academies of Sciences, Engineering, and Medicine reports Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care and The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, the Robert Wood Johnson Foundation’s Advancing Health Equity: Leading Care, Payment, and Systems Transformation program’s Roadmap to Advance Health Equity,^2,5 and Nundy.³

States and health care organizations could expand nonphysician practitioners’ scopes of practice to increase access to chronic-disease management services, mental health services, and substance use disorder treatment for rural and other underserved populations. Allowing all professionals to practice at the top of their license would improve teams’ efficiency. Despite predictions of doom, health care didn’t fall apart when scopes of practice expanded during the pandemic.

In 2021, the National Academies of Sciences, Engineering, and Medicine published two reports — Implementing High-Quality Primary Care and The Future of Nursing 2020-2030 (I was the Review Coordinator for the former and a member of the committee for the latter) — which recommend that teams partner with patients and communities to meet medical and social needs and that health care delivery organizations enhance employee well-being to prevent burnout. Flexible solutions could be tailored to people’s needs. Systems should work for both technology-savvy patients and technology neophytes and should address the digital divide. Patients and community representatives must have seats at the table when systems are being redesigned; relationships and trust are critical for chronic care.

Second, current reimbursement systems don’t adequately support the improvement of population health. We will need to level the playing field for chronic-disease care. When it comes to approval and reimbursement, new technologies and pharmaceuticals are often held to lower standards than holistic chronic-disease care processes, such as addressing social needs. For example, the Food and Drug Administration recently approved aducanumab (Aduhelm) for treating Alzheimer’s disease, despite its advisory committee’s recommendation against approval because of insufficient evidence of effectiveness and side effects including brain edema and microhemorrhages. The medication’s annual list price of $56,000 would pay a full-time home health aide for a year.

Third, our chronic-disease systems are inequitable. Health care delivery organizations, payers, and policymakers should intentionally advance health equity and address structural racism. The health care system will continue to put people experiencing poverty and other marginalized populations at the back of the line unless we intentionally value and address their health.⁵ For example, the Covid-19 vaccine-allocation guidelines from the Centers for Disease Control and Prevention (CDC) attempted to support equity indirectly by including frontline essential workers as a high-priority population in phase 2, but the agency rejected the National Academy of Medicine’s recommendation to prioritize regions identified in the CDC’s Social Vulnerability Index within each vaccination phase. The CARES Act Provider Relief Fund initially didn’t favor clinicians and organizations caring for populations with the greatest need; instead, it provided a windfall for wealthy health care organizations.

As poet Audre Lorde wrote, “The master’s tools will never dismantle the master’s house.” Health care organizations are struggling to address structural biases and racism internally and in the broader health care system. Relying on the same processes will produce the same results. Demonstration projects have taught us much about effective chronic-disease care programs,² and scholars have developed a road map that identifies root causes of inequities and integrates a culture of equity with the design and implementation of care transformations and payment reforms to address these causes.^2,5 A critical challenge involves redesigning payment systems to intentionally support and provide incentives for care transformations that improve patient health and patient experience and advance health equity, including by reducing disparities and addressing social determinants of health.^2,5 Clinicians, health care delivery organizations, and payers will also need coaching to translate lessons from successful processes and programs to their specific contexts.^2,5

The Covid-19 pandemic has forced us to step back, and the wider scenery has revealed uncomfortable truths about our chronic-disease systems. Too often, these systems are based on tradition, self-interest, and revenue generation — not on patients’ needs and health. We must recognize the health inequities caused by racism and self-interest and advocate for equitable chronic-disease systems that integrate human touch and relationships with lifestyle management, medications, and health technology and that address social needs and structural determinants of health.² We can design and implement effective chronic-disease systems if we lock on to the North Star goals of patient health, health equity, and justice.^3,5 The health care system encourages and rewards what is valued — which should be supporting the health of all people with chronic disease.

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