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Chronic Care William L. Roper Good evening. It is a pleasure to be with you and it has been an honor to serve on the committee. The task that was before us and we are pleased to describe for you tonight is a large-scale one. What is new about the endeavor we have undertaken at the request of Secretary Thompson is the notion of implementing a variety of demonstrations across the spec- trum of issues facing America's health care system, all at the same time. The federal government has long done demonstration projects to learn how to do things better. But they typically have been done only in one area at a time. The Department of Health and Human Services, of course, is probably the most demonstration-prone department within the federal government, but I don't think it has even been done in quite this fashion, across the spectrum of issues, all at the same time. What I am going to talk about for the next few minutes is the section focused on chronic care, but I want to stress a point that Gail Warden made a moment ago. These sections should not be seen in isolation. For example, one of the components of the chronic care demonstration is in- formation technology and we are anxious to demonstrate integrated ap- proaches to information and communications technology. So, these demonstrations might well fit together. The objective of the chronic care demonstration is to reduce the toll of chronic conditions on individuals and communities. I would stress the word "communities." This is not just about making individuals better but takes a population perspective. Our report and its approach tracks previous IOM reports and 6

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CHRONIC CARE other work done in the field. So, we are trying to build on the work that has previously been done. We are taking a two-pronged approach in the demonstration we have proposed. One is to redesign the health care delivery system to improve management of patients with chronic illnesses. Of course, the vast major- ity of expenditures in health care in America are focused on people with one or more chronic illnesses. But we also want to take a community-wide prevention approach, looking at how to make the whole population bet- ter. We envision a demonstration that would have the Centers for Medi- care and Medicaid Services issuing a Request for Proposals that would ultimately take 10 to 12 sites, likely in individual states. It is probably best for these to be done on a state basis, initially focusing on Medicare benefi- ciaries. The reason for this is severalfold. These are the patients who have the most chronic illnesses. Because the federal government has the most control on things and, therefore, can directly undertake innovations in this area, we envision that this would quickly, if done right, enable other payers to participate in such a demonstration. A second opportunity would be the patients who are eligible both for Medicare and Medicaid, but ultimately private payers in a given state might well choose to participate in this demonstration. We envision a one- year planning grant and three years for implementation. We think over time this would be budget-neutral but probably would require an initial investment for the information and communications infrastructure. We envision a four-step process that begins with establishing a coor- dinating structure to provide leadership within a state or a community. Such a structure might well include a consortium of health care provid- ers, community groups, businesses, or others in a community to enable that leadership and then to build out the community-wide information and communications technology infrastructure, establish chronic care management programs and, again, sponsor community-wide health pro- motion educational efforts. Step two focuses especially on the information and communications technology work. What we are planning is to identify in a given commu- nity or in a given state the various things that the experts in the field have been saying need to be done. We believe that a demonstration project of this sort is the best way to move forward. Step three involves implementing new models of care delivery. This requires the involvement of admitting physicians and other health pro- fessionals, hospitals, and other health care institutions with a real empha- sis on patient education and support, multidisciplinary teams and other caregivers, and outreach effort in the community. This would all be pulled together using the information technology that we have talked about.

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8 FOSTERING RAPID ADVANCES IN HEALTH CARE We continue to repeatedly stress the community-wide education ef- forts. Prevention and health promotion is a major part of this effort, along with primary prevention, early detection of illness, and slowing the pro- gression to chronic illness. That is our idea for a demonstration in the chronic disease area.