Why treating chronic diseases may be costing us more than we think
As a child, I remember sitting next to my father as he conversed with acquaintances and hearing him say things like, “You’ve had that pain for years. And the doctors can’t do anything for you?”
And the typical response was, “The doctor said that he’s doing all he can, that the medication should have worked and that maybe I should see a specialist or psychiatrist.”
Forty-five years later I hear the same types of conversations at family gatherings, coffee shops, checkout lines and, of course, doctors’ offices.
Not a simple category
The types of chronic diseases that are causing such consternation are a major thorn in the side of our healthcare system. I don’t mean conventional chronic diseases — diabetes, hypertension, anemia and others associated with aging, for example. Physicians tend to be well prepared to treat those types of conditions
The problem is with the nonconventional and not-so-well-understood types of chronic diseases.
Patients presenting with them complain of swaths of fatigue, pain, malaise, mental status issues, and generalized feeling of being unwell. To both patients and providers, the complaints can seem like a gerbil wheel to nowhere. Patients with chronic disease can be trying, demanding, vexing and problematic. It’s easy to wonder if they aren’t victims of hypochondria.
But that is not to say that these patients are hypochondriacs or that they cannot be treated. Nor is it always difficult to identify the root cause of the malady. Rather, the problem that we need to acknowledge is that our healthcare system too often leaves these patients at the proverbial train station to sit, often for years, waiting for help. We need to question whether our policies around payment and care protocols serve these patients as well as they should.
Understanding nonconventional chronic diseases – and the care challenges they present
Nonconventional chronic states can stem from hormone dysfunction, latent infection, immune abnormalities (or dyscrasia) and nutritional anomalies, among other causes. Such cases tend to exceed the usual cap on the amount of face time patients can spend with physicians and therapists, and they often strain conventional laboratory screening protocols, which prohibit additional testing if the screening tests cannot detect an underlying problem — or the results are not, as Marty Feldman of “Young Frankenstein” fame might say, “Abby Normal.”
Finance leaders need to understand the clinical concerns these conditions present if we are to begin curbing the avoidable costs associated with these conditions. Unfortunately, in many cases, in our effort to reduce cost, we are unwittingly impairing our ability to achieve true cost effectiveness of health. (See the sidebar below for examples of problematic nonconventional chronic conditions and why current approaches tend to be short-sighted.)
A diagnostic and cost imperative
Too often, when a patient’s chronic condition is not adequately diagnosed, the patient faces a future of constantly repetitive physician visits year after year with no meaningfully improvement to their condition. Yet physicians cannot accurately diagnose such condition if they are not afforded time to patiently and deeply investigate its etiology.
Essential steps would include a thorough history, a physical and all pertinent lab tests to provide a baseline for identifying potential causes of the condition and for monitoring treatment impact over time. A prudent assessment also would consider genetic factors (polymorphisms) that could affect treatment by causing variations in enzyme activity.
But how can a physician in a busy practice justify devoting additional time to such an investigation where time is already limited? And how could the additional payment for such an effort be justified?
The answer is to understand the opportunity costs of performing an extensive work-up upfront.
Consider that U.S. healthcare spending grew 9.7% in 2020, reaching $4.1 trillion, or $12,530 per person, accounting for 19.7% of the nation’s gross domestic product. Consider, too, that Americans with five or more chronic conditions make up 12% of the population while accounting for 41% of total healthcare spending. Better addressing these conditions could have an impact in reducing these costs.
Spending the time and money upfront would likely decrease the total load on the healthcare system in the long run by stopping the year-after-year cycle of avoidable office visits. It also would spare the patient the adverse effects of so many avoidable encounters with the healthcare system, including time lost from work, disruption of the patient’s psychosocial environment (family, self-worth) and reduced productivity to society..
Advice for finance leaders
So how might healthcare finance leaders approach this issue cost effectively? Here are some thoughts.
1 Creating a cost center understanding pertaining to upfront testing. This effort begins with anticipating the collective costs of performing thorough investigations of the causes on nonconventional chronic conditions with a laboratory work-up. It’s possible to gain a perspective on these costs by reviewing CMS fee schedules and outpatient CPT codes and comparing the findings with an estimated average number of visits and repeat testing (months to years) that would be required for each chronic disease. Pilot studies also could be commissioned to identify where such upfront costs would actually save money on the backend over time.
2 Partner with insurance companies. Finance leaders could engage in discussions with payers aimed at persuading them to share risk on such approaches, with demonstrations from research of overall cost savings, improved health and reduced resource allocations that could be realized over time by adopting them as the standard of care.
3 Engage your community. Various associations, societies and healthcare advocacy groups exist locally and nationally that would welcome clinical and other partnerships with healthcare organizations, yet all too often feel abandoned by the healthcare system. Many of these groups are focused on particular chronic disease states. By supporting or engaging with such groups in their advocacy, a hospital or health system can engender greater trust and allegiance from the public, thereby also fostering patient retention.
Chronic diseases have many faces, presentations and variations that may not fit well in the current medical architecture. Adapting our approach to explore other paradigms, while monitoring cost containment and resource allocation, is necessary to move medicine forward.
Examples of chronic conditions that defy ‘approved’ standard diagnostic protocols
In many cases, the underlying causes of chronic conditions may be undetectable using the standard methods approved by providers and insurers, requiring additional diagnostic steps that fall outside of standard diagnostic protocols and therefore may not be covered by the patient’s insurance. Following are common examples of such conditions.
Thyroid and adrenal disease. Before considering whether to order a thyroid or adrenal panel for fatigue or insomnia, a physician typically would order a thyroid-stimulating hormone or a single cortisol level. And if the results fall within normal limits, practice or insurance-mandated guidance would often preclude any further thyroid or adrenal testing. Yet thyroid disease affects up to 5% of the general population, with a further estimated 5% being undiagnosed. Moreover, many such diseases increase with age.
And, despite having a “normal” thyroid stimulating hormone (TSH) screening test result, they may have underlying (subclinical) disease, where their condition is, in fact, detectable. Patients with thyroid disease can, in fact, have evidence of other physiological thyroid biomarker abnormalities, including T3/T4 as well as the presence of antithyroid antibodies. In fact, estimates of specific thyroid-related total medical costs can range from $460 to $2,555 per patient per year, and can affect higher all-cause medical costs and medical resource utilization, higher absenteeism and long- and short-term disability costs. these patients often go from physician to physician — and often from job to job — because today’s busy practice of medicine does not make time to address their issue, with potentially serious consequences: The American Thyroid Association notes, “Undiagnosed thyroid disease may put patients at risk for certain serious conditions, such as cardiovascular diseases, osteoporosis and infertility.” Adrenal gland disease states and sequelae of delayed diagnosis can have similar negative implications.
Chronic conditions emerging from infections. Such conditions represent another quagmire. Conventional wisdom dictates that infection generally manifest in a particular way, be confirmed with lab results and be resolved after administration of appropriate antibiotics.
But what happens when things do not follow the expected course? For example, conventional childhood streptococcal infections are usually resolved with antibiotics. Sometimes, however, a “strep” infection does not manifest in the classical way (sore throat, fever). Rather, it can elicit sudden changes in behavior that manifest as obsessive-compulsive disorder (OCD), tics, mood changes, anxiety and/or irritability. This phenomenon has been referred to as Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS), which has been associated with recent strep infection, whether or not manifesting with the expected clinical symptoms. Accurately diagnosing such conditions takes time.
Another perplexing constellation of symptoms resides with spirochetal infections. A classic course for a spirochetal infection can be that of Lyme disease (Borrelia burgdorferi). Rather than experiencing the typical rash, joint/muscle pain, headache and fever that occur after the bite of a deer tick, those infected with Lyme disease may manifest with nonconventional symptoms such as pain, fatigue, cognitive difficulties and psychotic and mood symptoms, which can occur years after treatment. These are symptoms of a related, chronic condition, referred to as Post-Treatment Lyme Disease Syndrome (PTLDS), which is secondary to the inflammatory mediated neurodegenerative damage patients incur during the initial infection, while also being harder to diagnose. Various treatment approaches, including long-term antibiotic treatment, herbs and essential oils among others, have been reported with various success outcomes.
These conditions have significant cost ramifications, given that the annual cost per patient of treating Lyme disease amounts to roughly $3,000. Moreover, research shows that, compared with controls, it requires 87% more outpatient visits over a 12-month period and is associated with 4.77 times greater odds of being diagnosed with PTLDS. Similar concerns can occur with other spirochetal and parasitic infections.
Other non-conventional conditions — including small intestinal bacterial overgrowth and, the newest kid on the block, long COVID — also present challenging health and related economic issues.