Meeting the Challenge of Chronic Illness

My grandfather once remarked that getting old and living with a chronic illness wasn't so bad, when you consider the alternative. His wry resignation captures perfectly the sentiment of many of my older patients, an attitude that I find increasingly shared by other stake-holders in chronic illness care, such as physicians, pharmacists, nurses, and administrators. Meeting the Challenge of Chronic Illness seeks to shake us from our collective acquiescence by sounding an alarm to the coming crisis of a population that is ageing with chronic illness, a care system that is marked by disparate and uncoordinated health services, and costs that are rising at unsustainable rates.

The book, however, lacks the urgency and stridency of a call to quarters and wisely does not offer a single solution to improving chronic illness care. Rather, in an academic and sometimes repetitive style, the authors explore ways to advance chronic care, and introduce several underlying principles and essential components of an idealised care system, many of which are based on the Chronic Care Model (CCM). Although the CCM has not been fully implemented or tested, various elements have been found to reduce costs and improve health outcomes, and have spurred several chronic care pilot programmes, most notably in the Medicare Prescription Drug Improvement and Modernization Act of 2003.

The heart of the problem, according to the authors, is that the conceptual model of care in the United States is all wrong, one structured on acute care that is ill equipped for people with chronic conditions. Although I very much agree, Meeting the Challenge of Chronic Illness misses the mark by failing to take clear aim at the traditional, fee for service Medicare programme that continues to dominate the organisation and financing of chronic illness care. This is a major shortcoming. Some of the proposed key principles of an idealised chronic care system are the same principles that under-gird the present conceptual model of care. For example, Medicare's roots are in indemnity insurance, where patient preference is a major driving force, yet a person centered focus is a core tenet in the health care system envisioned by Kane, Priester, and Totten. Fundamentally changing the structure of chronic illness care is predicated up on understanding the historical, social, and political forces that gave birth to Medicare over 40 years ago, and continue to shape it today.

Despite these limitations, Meeting the Challenge of Chronic Illness remains a good primer for those interested in understanding chronic illness care and is a sound meteorological report of the major storm brewing in health care. Unfortunately, I share the authors' forecast that it will take a crisis—the perfect storm—to effect real change. Perhaps only then, like my grandfather, we will all consider an alternative to the present care system for chronic illness.

Figure 1.

Robert L Kane, Reinhard Priester, Annette M Totten

The Johns Hopkins University Press, $55, pp 328 ISBN 0 8018 8209 5 www.press.jhu.edu

Rating: ★★★⋆