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What should be incentivized in care of chronic illness?

Chronic illness is the dominant health problem bedevilling health services in the Western world, and increasingly elsewhere. Chronic illness causes most unnecessary hospitalizations. Dixon’s thesis is that by rewarding a reduction in unnecessary hospitalization, the quality of upstream care of the chronically ill will be improved. Unfortunately, unnecessary hospitalization is the last step in a chain of prior care events that must be altered to avoid hospitalization. The reason why chronic disease is such a problem is that we continue to use acute care treatment methods to manage it. This is so because the structures and practices of most contemporary healthcare systems were developed during the first half of the last century, when acute disease was dominant. During the second half of the century, the prevalence of chronic disease rose to the point where today it is the major cause of disability and use of health services and, in the USA, now consumes 80% of healthcare expenditure. However, healthcare systems, the health professions and medical education have failed to adapt to the change in disease character. Thus, they remain confronted by a dominating problem for which they were not designed. What are the differences between acute and chronic care? Care of chronic disease is not the decisive process of precise diagnosis, definitive treatment and cure typical of acute disease treatment. In the absence of cure, chronic disease care becomes an unfolding, multivariate, continuous management process. It has a different strategy (not cure, but maximizing the comfort and function of the patient) and different tactics (not just medicine or surgery but also behaviour change, social and work circumstance changes, environmental modification and emotional adjustment). Different roles are required of the patient, the physician and other health professionals, and of health services and financing. For good chronic illness care, the patient becomes a principal care-taker who must be knowledgeable about and participate in most of the aforementioned care tactics and in management decisions. The health professionals become partners with the patient, providing medical knowledge and helping the patient to learn new management skills. The health system provides the necessary facilities, ensures continuity and integration of care, and supports essential programmes such as electronic records, patient selfmanagement education and home care. Such goals do not require new construction or new technology, but rather new attitudes and new behaviours. To my knowledge, the goals have not been achieved in any national health system. It is illustrative that, in a 2001 Johns Hopkins study, some 65% of practising US physicians reported that they were poorly trained in nine competencies considered necessary for good chronic care. An accompanying analysis of 16 representative US medical curricula showed poor importance given to 22 out of 49 consensus components of good chronic care and, on average, none was rated as essential. However, portions of the needed care do exist in some subsystems, as represented, for example, by the chronic care model of medical practice. I do not know how the National Health Service or British medical education measure up to such criteria for good chronic illness management. But, whatever the