Chronic problem: Treating chronic disease a huge cost to all

Talk about it

FARGO — Lucille Johnson’s warning arrived one day when she unexpectedly grew short of breath during a routine walk home from her daughter’s house a mile away.

The flat terrain ordinarily made for easy walking, but Johnson’s breathing suddenly became so labored that she sat down on the curb to catch her breath.

“All of a sudden I just couldn’t breathe,” she said. “I had a hard time getting home.”

It turned out the culprit was high blood pressure. Untreated, hypertension, sometimes called the “silent killer” because symptoms often are hidden, can lead to kidney damage, heart attack or stroke.

But high blood pressure is common, especially among the elderly. Johnson’s problems, for instance, arose about the time she turned 65.

As a chronic condition, which can be treated but not cured, high blood pressure, along with such diseases as diabetes and asthma, accounts for a growing and largely preventable part of health care costs.

Nationally, three of every four health care dollars are spent treating chronic disease, according to the Centers for Disease Control and Prevention.

At least half of an organization’s health care costs are driven by lifestyle behaviors, such as smoking, poor diet and lack of exercise, according to North Dakota Worksite Wellness, an initiative to help employers develop worksite wellness programs.

The cost of physical inactivity in North Dakota is estimated at more than $990 million, including medical costs, workers’ compensation costs and lost productivity, the group calculates. Almost three of every four residents do not get regular daily exercise.

Here’s a more ground-level glimpse of how caring for chronic disease adds up in dollars and cents:

Blue Cross Blue Shield of North Dakota last year budgeted on average $6,800 for every member who has diabetes, $4,000 for each member with asthma, $7,000 for chronic heart failure and $5,000 for hypertension.

Now for the inflation factor: Those amounts are up about 50 percent from 2005.

Health management

To restrain those escalating costs, more intensive management of patients with chronic conditions has emerged as a major strategy.

Health systems are pairing patients with nurses or health coaches to better manage their conditions.

In the case of Lucille Johnson, it means regular visits with her care management nurse, Yvonne Braun, at Sanford Health.

The two were paired several months ago when Johnson’s doctor recommended a care management nurse to help her regulate her blood pressure, which was prone to spikes despite efforts to control it, including medication and diet.

After an initial meeting, most of their visits are by phone, with Braun checking in to see if Johnson is meeting her exercise goals and diet restrictions, including avoiding salt and caffeine.

“Just kind of those reminders for patients,” Braun said, adding that Johnson actually is conscientious about sticking to her regimen.

Also, Johnson can call her care management nurse whenever she has a question or is troubled by something, such as an unexplained elevation in her blood pressure.

“Now I just feel so much more comfortable because I can call you,” she recently told her nurse.

Johnson isn’t alone. Care managers or health coaches at Sanford’s family medicine and internal medicine clinics in Fargo have seen almost 10,000 patients within the past year.

Better care coordination at internal medicine clinics is showing results, according to Sanford figures, with higher tetanus vaccination rates and screenings for colorectal cancer, mammograms and smoking cessation rates among diabetes patients.

Improved continuity of care, and the relationships that can develop between a patient and care management nurse, are an important ingredient of the better results, said Dr. Julie Blehm, an internal medicine doctor who oversees Sanford’s care management program.

“Patients didn’t really like being called by someone they didn’t know,” she said. “Not every bit of this needs to be face-to-face, but we thought the relationship part of this was critical.”

Care management nurses are trained in motivational interviewing and finding ways to help patients overcome obstacles to better health. Ignoring those obstacles, or making unrealistic demands on the patient, is a formula for failure, Blehm said.

“Our nurses now are quite good at this, the experienced ones,” she said. “We’ve had some great success stories. None of them overnight.”

A few years ago, a pilot study of care management of chronic illness found “medical home” patients treated by care teams saved $530 per patient a year.

The study, involving MeritCare (now Sanford) and Blue Cross Blue Shield, also found hospital admissions dropped by 6 percent and emergency room visits plunged by 24 percent.

Still, the savings achieved from care management represented only a slowdown in rising costs, not a reduction of costs.

The payoff

In another approach to contain health costs, insurers are starting to work more closely with employer groups to improve employees’ health, and therefore save money.

Part of the new strategy involves studying the population of employees to identify those who are most at risk for expensive illness, then to devise prevention plans.

“Ideally the goal is to save money and help people live healthier lives,” said Mike Potts, an assistant vice president at Blue Cross Blue Shield who works with employers on wellness programs.

The tailored, consultative approach is increasingly sought by employers who are struggling with rising health insurance costs.

“Employers wanted these programs,” said Paul von Ebers, president and chief executive officer of the North Dakota Blues. “Now they’re coming back and saying, ‘Can you show us the results?’”

Results can take the form of lower health costs – or at least less dramatic cost increases – as well as lower absenteeism rates, workers’ compensation costs, and higher productivity rates.

Earlier versions of workplace wellness programs were basic, focused on helping employees lose weight or stay active. But the new approach is more sophisticated, involving “data mining” claims to spot trends and offer advice.

“That’s very valuable to our groups,” said Dr. David Hanekom, the Blues’ chief medical officer.

To help people stay on track with diet or exercise goals, it helps to have them working together as members of a group. So some workplaces are adopting “lunch and learn” healthy lifestyle programs, and office exercise centers.

“We know group reinforcement really works,” von Ebers said.

But health insurance executives acknowledge that results can be hard to measure, and can take time to become evident.

Containing health care costs is both a long-term project and a work in progress.

“It takes time to show results,” Hanekom said. “It may take years to show results.”

Fortunately for Lucille Johnson, results have come more quickly. Her blood pressure is better controlled than it once was, thanks to medications and alterations in her lifestyle.

“I learned I can drink decaff,” she said, referring to coffee. She exercises several times a week, including frequent walks, aerobics classes and weight training. She also uses a relaxation method that helps her sleep.

“It’s hard to know what more I can do,” Johnson said.

“What I’m trying to avoid now is I don’t ever want to have one of these spells again,” she said, referring to blood-pressure spikes like the one she experienced walking home from her daughter’s. “That is scary.”

Springer reports for Forum Communications Co., which owns the Herald.

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