Chronic disease care

Two papers in this issue of BMJ examine developments in the management of chronic illness in the United States and explore their potential relevance to recent NHS initiatives and policies.¹,² A new King's Fund study of the care of chronically ill people in five leading US managed care organisations, summarised in the paper by Dixon et al (p 220), provides several observations and insights of relevance to new NHS initiatives targeting care of chronic illness.¹ The authors conclude that the success of these organisations relates to five factors, which serve as the basis for their recommendations for NHS action. With some minor exceptions, I believe that their observations and recommendations are on target and worthy of serious consideration by policy makers in the United Kingdom.

Competition

The investigators were struck by the intensity of market forces in US health care and although these contributed to variability, excesses, and doctors' discontent, they came away convinced that market forces pushed organisations to improve their quality.³,⁴ This is debatable. The perceived lack of a compelling business case for quality reinforces the market pressures to control costs and compete on price rather than quality.^{5 w1} The investigators are well aware that the wrong kind of market pressures could be disruptive and even a threat to quality of care and are appropriately cautious in recommending steps to foster competition within the NHS.

Ownership and exclusive contracting

Relationships between the managed care organisations and their clinicians were found to vary within and between organisations. Two managed care organisations contract exclusively with one or two medical groups. In a third, contracted doctors care for subscribers of multiple managed care organisations. The remaining two use a mixture of exclusive and non-exclusive contracts. Although few research data show quality advantages for one managed care organisation's model over others,⁶ the report concludes that exclusivity of relationships fosters greater commitment by clinicians to organisational success, involvement in decision making, and closer relationships with managers of managed care organisations. In return managed care organisations are more willing to invest in frontline infrastructure such as clinical information systems. My experience in one of the two mixed model managed care organisations strongly confirms the advantages of exclusive relationships.

Integration between providers

The report underscores the importance of linking and coordinating primary and specialist care for patients with chronic illness. Some evidence shows that closer integration of primary and specialist care improves health care for individual patients^{7 w2 w3} and for populations of patients.⁸ In some of the managed care organisations studied this is made easy by their membership in the same medical group or presence in the same physical facility. In others, functional linkages are created through shared information, shared guidelines, and staff to coordinate care (for example, case managers). In all organisations health care is facilitated by the alignment of goals—for example, to minimise hospitalisation—between the primary care and specialty sectors. Alignment of goals and promotion of coordinated care by teams consisting of generalists and specialists—as in the personal medical services pilots⁹—should be a high priority.

Financial incentives

Financial incentives to reward high quality chronic illness care are important elements of the strategies of managed care organisations studied. The incentives tend to be modest, in the range of 5-10% of salary. This amount is felt to be large enough to change clinical behaviour, but not so large as to encourage inappropriate or fraudulent efforts to obtain a bonus. In addition to giving incentives to individual clinicians some managed care organisations offer incentives to contracting medical groups to reward high quality care. Evidence from a recent study of randomly sampled large US medical groups found that organisational incentives encouraged the implementation of system improvements supportive of better chronic care.^w4 The efforts in the NHS to build performance based incentives into contracts is clearly a step in the right direction, if based on credible indicators of better care and trustworthy measures.

Clinical process: chronic disease management

All five managed care organisations use explicit models and strategies for improving their systems of care. All have made comprehensive changes to their systems to encourage and support better care, including more support for self management by patients, more structured visits and patient follow up, clinical case management of more complex patients, and enhancements to decision support and clinical information systems. These changes are consistent with the chronic care model, a synthesis of system components and strategies associated with effective care across conditions.^w5 Three managed care organisations explicitly use the chronic care model as the guide to changing systems.

In their paper on page 223, Lewis and Dixon relate policy developments in the NHS to the elements of the chronic care model and conclude that recent NHS policy and planning initiatives are addressing many of the essential elements of high quality chronic illness care.² But these efforts would benefit from a “clear generic model of disease management.” To be more relevant to the British context, the chronic care model or any other model must link the macro policy environment to frontline care and the needs of patients.

These two papers, on balance, show that the recently launched NHS push to improve care of chronic diseases is on the right track and is likely to have much to teach the United States and other countries. The growing epidemic of chronic diseases in developing countries will be one of the topics covered in the BMJ's fourth theme issue on chronic disease care in January 2005.