Redesigning the management of chronic illness.

IT IS WIDELY RECOGNIZED that health care expenditures in the United States are increasing at unsustainable rates, and pressures are mounting for finding effective cost containment strategies, especially those that maintain access to care and assure quality. In 2004, health care spending will reach $1.6 trillion, or $6,167 per capita. Moreover, pre-Medicare Prescription Drug, Improvement, and Modernization Act estimates suggest that health care expenditures in the United States would reach $3.4 trillion and 18.4 percent of the Gross Domestic Product (GDP) in 2013, up from an estimated 15.5 percent of the GDP in 2004.1 The problem will be exacerbated in the United States by changes in the demographic composition and the aging of the population, albeit at lower levels than predicted earlier.1,2 If change does not occur from within the health care system to alter the traditional patterns of delivering medical services to improve efficiency, create effective substitutions, and streamline the care process, changes—likely more arbitrary—may be imposed upon it by forces outside the system. Few would disagree that we are near, if not already in, a health care crisis that is best averted rather than experienced. By necessity, employers and payers in the public and private sectors will continue to look for ways to contain health care costs, hopefully without denying care for those who need it or jeopardizing quality of care. Traditionally, cost containment strategies have focused largely on price and payment method and not on the care process. While strategies to minimize payor reimbursement may have reached their limit, opportunities for additional cost containment may exist if we find more effective ways to deliver care to patients with chronic illness. From a broad societal perspective, economic pressures on the health system come at a time of ever-expanding diagnostic and therapeutic capabilities and technologies that reduce morbidity and save lives, but also add to the cost of care. From the perspective of the chronically ill patient, opportunities for improved diagnostic procedures, drugs, and other therapeutic interventions have never been greater. The challenge for the health system is how to provide access to these opportunities while containing cost.