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Reform Chronic Illness Care? Yes, We Can
Ah, humanity. Having eliminated many causes of acute diseases, we’ve achieved longer lives plagued with chronic ones. Sometimes we pass along genetic defects that predispose our offspring to these conditions; more often, we help bring chronic illness upon ourselves, through environmental exposure or our own lifestyles. Now three-quarters of the $2 trillion-plus that we spend on U.S. health care each year goes to paying the bills for chronic illness: cardiovascular and pulmonary disease, cancers, diabetes, arthritis, high blood pressure, depression. Globally, the World Health Organization (WHO) estimates, three out of every five deaths—four out of five in low- and middle-income countries—stem from chronic disease. Hence this thematic issue on chronic care, funded in part by the pharmaceutical companies Eli Lilly and Company and Wyeth (both of which obviously make many products aimed at combating chronic illness). The papers that follow deal with the broad spectrum of chronic care in the United States and abroad. They underscore that to a considerable degree, delivery system reform will be chronic care reform. After all, even the care given to patients in hospitals increasingly goes to those in acute phases of chronic illness. As in many things in health care and health spending, American "exceptionalism" is the rule: The United States is doing an especially rotten job of delivering chronic care, at spectacular cost. In a Health Affairs Web-Exclusive study published 14 November 2008, Cathy Schoen and her Commonwealth Fund colleagues reported on a survey of 7,500 chronically ill patients in eight countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. The survey shows that U.S. patients are far more likely than those in the other countries to report high out-of-pocket costs; to forgo care due to the expense; and to experience high rates of medical errors. Misery, however, loves company—and many of America’s industrialized-nation peers don’t do an especially great job of delivering chronic care, either. At the heart of the problem is lack of care coordination. Except in the Netherlands, at least one in five patients in all countries report that test results and records aren’t available at the time of a medical appointment, or that doctors order tests that duplicate those already done. These problems seem to cut across countries whether or not they have universal coverage, and regardless of insurance benefit design or other factors. So what is it—other than the drive toward entropy—that keeps countries that manage to do many other complicated things from providing seamless health care to predictable populations? The question is well worth considering in the current U.S. political context. The election of Barack Obama as president, along with a decisively Democratic Congress, has set the stage for sweeping health reform. But expanding insurance coverage and access, as important as those are, clearly won’t be enough to make our nonsystem of chronic care functional. The papers and Perspectives in this volume offer clear examples of models worth emulating far more broadly. As Katie Coleman and colleagues report, the evidence continues to pile up that the famed Chronic Care Model developed by Ed Wagner and colleagues at Group Health Puget Sound delivers superior patient care and health outcomes. (The evidence is starting to trickle in about the model’s overall cost-effectiveness.) And as Susan Brink recounts in this issue’s Report from the Field (the fruits of Health Affairs’ partnership with Kaiser Health News), there’s ample evidence from the randomized clinical trial known as the Diabetes Prevention Program that some chronic disease prevention strategies work. The challenge now is to roll out these models and strategies in cost-effective ways, because even if they’re not truly cost-saving, they are crucial investments in our future. After all, the WHO says that eliminating chronic disease risk factors such as unhealthy diets, smoking, and physical inactivity could wipe out at least 80 percent of all heart disease, stroke, and type 2 diabetes worldwide. Can we achieve that? We should be inspired by the recent U.S. presidential election campaign: Yes, we can.
Note To Prospective Authors: We are now posting requests for abstracts for papers tied to our thematic issues on our Web site. For details, please visit http://www.healthaffairs.org/Future_theme_issues.php
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