Chronic disease care: rearranging the deck chairs.

The care of patients with chronic disease is one of the most urgent medical challenges in the United States. Chronic illness accounts for most of the demand, expense, and investments in scientific discovery. The well-documented shortcomings in medical quality and safety fall heavily on the shoulders of patients with these conditions (1). Meanwhile, the Medicare program moves steadily toward insolvency (2). Two major trends will seriously aggravate the current situation. Over the next 20 years, demographic changes will drive a substantial increase in the prevalence of chronic diseases. Moreover, scientific advances will greatly expand our ability to diagnose, to treat, and to monitor chronic diseases (3). Our imperative, therefore, is to find models that can reliably and consistently deliver high-value care (highest possible quality and lowest possible cost) for patients with chronic illnesses. Two articles in this issue address this matter. Chodosh and colleagues (4) screened 780 studies to find 53 that could be used to determine whether self-management programs for older adults with 1 of 3 chronic conditions (diabetes, hypertension, and osteoarthritis) would produce improvements in specific clinical outcomes associated with those conditions. The authors concluded that such programs can improve outcomes in diabetes and hypertension but not in osteoarthritis. The evidence was too scanty to assess the cost-effectiveness of these programs or to determine what elements can be generalized to other chronic conditions. Wolff and Boult (5) took a different tack. The authors provided a useful review of a broad sample of chronic disease management studies and summarized current efforts in the Medicare program to incorporate some of these advances. They concluded their discussion with several suggestions for future inquiry. The articles are useful and notable for their rigor (Chodosh and colleagues) and their comprehensiveness (Wolff and Boult). But they must be read with caution. Studies of a single intervention divert attention from the underlying issues. In my 21 years with Kaiser Permanente, I learned that the bigger picture combines who the health care providers are and how they interact with each other, the way support staff function, the presence or absence of clearly defined care pathways (guidelines), the use of diagnostic and therapeutic technologies, the architecture of the information and communications infrastructure, the design and operation of the clinical decision-making systems, and the existence of real-time evaluation and learning loops, all applied over the lifetime of a chronic illness. A silver bullet won’t cure what ails us. For this reason, I suggest that Wolff and Boult are incorrect in describing the current Medicare approach as “aggressive” experimentation with chronic disease management alternatives. Notwithstanding the treacherous political waters that Congress and the administration must navigate, these experiments are notable for their timidity. The well-documented deficiencies in chronic disease care and the magnitude of the challenges ahead cry out for efforts that go well beyond tinkering around the edges of this urgent and complex problem. Wolff and Boult’s proposed recommendations for further exploration do not go far enough. Closer ties to primary care, more comprehensive cost–benefit studies, creation of a “medical home” for the patient, and better training for physicians are timeworn friends. These strategies can help, but, like using a pellet gun to stop an onrushing elephant, they aren’t up to the challenge. Our goal must be to identify the combination of essential delivery system “production” factors that can consistently deliver care of greatest value for patients over the lifetime of their illnesses. Chronic disease management requires a complex array of physician and nonphysician specialists, support staff, infrastructure, sciences, technologies, patient and family skills, and community linkages that must be integrated across multiple venues over time. These pieces can fit together in many ways, but little is known about how different combinations influence quality and cost over time. Even less is known about how to manage these processes day in and day out to produce the consistently high-value outcomes seen in other industries. The impact of a specific tool or intervention, therefore, is not the central issue. Instead, we must accelerate and expand our search for the underlying chassis: the combination of organizational models, care delivery production systems, and payment systems that can reverse the shortcomings in today’s chronic care, meet the demand that lies ahead, and incorporate the new diagnostic, treatment, and monitoring tools that are on the horizon. Our seriously constrained physician and nurse supply adds further urgency and complexity to the task. The United States requires a comprehensive, innovative, and appropriately funded research and development agenda to address the growing crisis in financing and delivering chronic disease care. Whether we place new chairs on the deck or rearrange the old ones, such inconsequential actions cannot save us from the icebergs that lie in our path. We urgently need to change course.