Marshall H. Chin, M.D., M.P.H.
“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
- Ensure that patients are central and are the system’s compass.
- Set goals centered on best achievable health and patient experience.
- Empower patients and families to collaborate with the care team.
- Partner with patients and communities in creating and implementing new care systems.
- Ensure that systems synergistically support patient and employee well-being.
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.
Fulfillment of system-level health and social needs
- Address systemic issues that drive inequities.
- Work to dismantle structural racism within and outside the health care system.
- Collaborate with community partners to address social and structural factors affecting patients’ health, including by generating and sharing real-time data.
- Develop trustworthiness.
- Be guided by a road map for advancing health equity.
- Stratify clinical performance measures and patient-experience metrics by factors such as patient race and ethnic group and socioeconomic status.
- Perform root-cause analysis of health disparities.
- Design care interventions to address root causes.
- Create a culture of equity that enables implementation of reforms.