Managing chronic diseases

Editor—DiPiero and Sanders identify economic disincentives in payments models and propose fees-for-conditions to encourage innovation consistent with the chronic care model and to reward superior results.¹

In September 2003, chronic care practice enhancement payments were introduced in British Columbia as part of implementing the chronic care model.² The patient's general practitioner became eligible to receive an annual payment of $C75 (£32; $60; €47) for each patient with a confirmed diagnosis of diabetes mellitus or congestive heart failure for whom a flow sheet maintained in the patient's chart documented care consistent with the approved provincial clinical practice guidelines.³ These payments are in addition to the normal fee for service payments for patient care.

Over half the family doctors in the province are now participating, and the payments give them financial flexibility to allow experimentation and innovation in practice redesign. Doctors have accepted payments tied to guidelines and the use of performance measures⁴ but are reluctant to see payments tied to actual results as they are often beyond their control.

Payment reform is a necessary but not sufficient condition to implement the chronic care model. Doctors need support through the process of change. Complementary elements include help with the development of patient registers; developing flow sheets as decision support tools; central storage of flow sheets electronically to enable sharing with other healthcare providers; and support for patient self management.

Our experience shows that small incremental changes to an existing fee for service system are acceptable and effective. Our next step, planned for this year, is to extend the range of chronic disease covered by the payments, and to continue to evaluate and report on the outcome.⁵