Statement of Robert Bonow, M.D., President-Elect, American Heart Association

My name is Robert Bonow, MD, and I am the president-elect of the American Heart Association.  On behalf of the American Heart Association and its over 22.5 million volunteers and supporters, I am pleased to submit this statement for the hearing record.

Since 1924, the American Heart Association has dedicated itself to reducing disability and death from cardiovascular disease and stroke through research, education, community-based programs and advocacy.  Providing effective, credible scientific information is vital to our mission.  The American Heart Association and the American Stroke Association, a division of the American Heart Association, actively participate in efforts to improve the delivery of disease-specific health care through the widespread adoption and implementation of scientifically based standards and guidelines. 

Cardiovascular Disease and Stroke Contribute Significantly to Chronic Illness in the United States

More than 125 million Americans have at least one chronic illness.  This number is approximately 40% of the total U.S. population, and approximately 40% of those patients have at least two chronic conditions.  The direct medical costs of chronic conditions in the U.S. will total $600 billion per year, and the care and management of patients with chronic disease represents the single largest cost to our health care system.[1]  Significantly, the cost of cardiovascular disease and stroke in the United States in 2002 is estimated at $329.2 billion.

Of these chronic illnesses, cardiovascular disease accounts for almost as many deaths as the next seven leading causes of death combined, costing this country almost $300 billion a year in healthcare expenditures and lost productivity – more than any other single disease.  Some 60 million Americans – about 1 in 5 – suffer from some form of cardiovascular disease, ranging from high blood pressure to myocardial infarction, angina pectoris, stroke, congenital vascular defects and congestive heart failure.  One form of cardiovascular disease alone, heart disease, is the number one killer in the U.S., and another form of cardiovascular disease, stroke, is the third leading killer.

Disease Management as an Approach to Confronting Chronic Illness

Disease management is one strategy used to confront the challenges presented by chronic illness.  It is a term widely and inconsistently used.  Hundreds of “disease management programs” exist for a wide array of chronic illnesses, including congestive heart failure, diabetes, asthma and depression.  Increasingly, disease management is being offered as an approach to health care management in the public and private sectors.  For example, Federal agencies are currently evaluating the cost effectiveness and patient outcomes of programs that rely on disease management techniques to deliver patient care; a number of states are offering disease management services through their Medicaid programs; key members of Congress are introducing legislation to fund new disease management initiatives; and pharmaceutical benefit managers (PBMs) are contracting with states to provide disease management services through pharmaceutical assistance programs for seniors.  There are as many definitions of “disease management” as there are programs that claim to provide disease management services.

Although advocates for the approach argue that it lowers costs, improves patient care, and allows for effective evaluation of services, some policy experts suggest that disease management programs may actually lower costs at the expense of patients’ healthcare needs, or alternatively, that it may actually increase health care costs through added services (which may include administrative costs and other indirect costs).  In addition, the effectiveness of disease management in improving clinical outcomes is currently being evaluated.[2]

The American Heart Association Urges Policymakers to Focus on Quality as the Guiding Principle

Disease management is an evolving concept.  As government, health plans and clinicians have adopted disease management models to fit their own needs and goals, the various meanings of disease management have diversified.  In practice, disease management can cover a range of potential activities, from distributing pamphlets to patients that instruct them on self-management techniques related to their particular condition to relying on a case manager to develop patient-specific care plans.[3]

The American Heart Association finds the concept of disease management promising, but also urges the Subcommittee to consider two issues –

(1) any quality standards or performance measures for cardiovascular disease and stroke must be based appropriate, objective and scientifically-derived, evidence-based guidelines; and

(2) quality of care must be prioritized over cost-containment or other financial incentives in all disease management initiatives.  Disease management should be primarily about improving patient outcomes and only secondarily about cost containment.

For disease management to truly put patients first, clinical guidelines must rely on a template that emerges from medical community consensus.  Additionally, appropriate disease-specific programs should reach low-risk patients as well as high-risk patients to best serve long-term health needs.  In short, to focus on appropriate patient-centered clinical guidelines, medical community standards must serve as the fundamental framework for any disease management program that hopes to draw widespread approval and acceptance. 

How Congress chooses to confront this issue for Medicare beneficiaries will likely impact the entire U.S. healthcare system.  As noted in a recent MedPAC report to Congress, “...because Medicare is the single largest purchaser of health care in the country, its actions influence the care that all patients receive nationwide.”[4]

The American Heart Association Provides Leadership and Consensus

It is fitting that the American Heart Association adds its voice to the many that are currently speaking to the issue of disease management.  Although within most clinical areas there are many organizations, health plans and manufacturers that promote clinical guidelines based in part on the clinical literature, few organizations have the expertise or resources to establish and continually update consensus based standards that represent a holistic view of cardiovascular and stroke care.  Importantly, the American Heart Association represents not just providers but all stakeholders in cardiovascular and stroke care – physicians, nurses, emergency medical support personnel and others.  Most significantly, the American Heart Association represents the patient. 

The American Heart Association is at the forefront of investigating ways to improve the quality of care for patients with cardiovascular disease and stroke.  We have developed and are currently operating a number of patient-centered programs.  Our programmatic efforts have increased and evolved with the dynamic advances made in cardiovascular and stroke care. 

In essence, the American Heart Association’s existing programs and guidelines provide a foundation for managing disease.  We are extremely proud of the process through which our guidelines are developed and place great emphasis on ensuring objectivity and sound science.  The American Heart Association and the American College of Cardiology have developed joint guidelines on the treatment and management of heart disease, including guidelines for acute myocardial infarction, unstable angina, congestive heart failure, chronic coronary disease and secondary prevention. 

The American Heart Association and the American College of Cardiology also work in partnership in the development of performance measures, including developing measures for acute myocardial infarction and chronic heart failure.  The American Stroke Association, a division of the American Heart Association, develops scientific guidelines for managing and treating stroke and is currently developing performance measures for stroke.

Our programs are developed based on our scientific guidelines.  The following is a brief description of two of our programs designed to improve the quality of care for cardiovascular and stroke patients.

The American Heart Association’s work on disease management is ongoing.  We are currently reviewing various models of disease management, particularly in the area of cardiovascular disease and stroke. We are analyzing the effectiveness of these models and hope to use this information to refine our current policies, programs and other efforts, if needed. 

Conclusion

In addition to the use of appropriate clinical guidelines, it is critical to ensure that disease management programs are driven by the clinical needs of patients rather than cost containment or financial profit.  While we recognize the need for cost containment and careful allocation of health care resources, improving the quality of care must be the primary goal of any disease management program.  The American Heart Association appreciates the opportunity to provide these comments to the Ways & Means Health Subcommittee on this timely and important issue, and we look forward to working with the Subcommittee as it continues to consider the appropriate integration of disease management into the Medicare program. 

[1] Lawrence Fisher & Karen L. Weihs, Can Addressing Family Relationships Improve Outcomes in Chronic Disease? 561 Journal of Family Practice 561 (June 2000).

[2] Finley A. McAlister et al., A Systematic Review of Randomized Trials of Disease Management Programs in Heart Failure, 110 American Journal of Medicine 378, 381 (April 1, 2001). 

[3] Jeff Tieman, Disease Management Making a Case for Itself Clinically and Financially, Modern Healthcare, July 9, 2001. 

[4] Medicare Payment Advisory Commission (MedPAC), Report to the Congress: Applying Quality Improvement Standards in Medicare (January 2002).