Health Affairs Special Edition: The Crisis in Chronic Disease

Is the Health Care Workforce Ready for Chronic Care?

The January/February Issue of Health Affairs was devoted to the "Crisis in Chronic Disease." Health Affairs Editor-In-Chief observes: "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." Several excellent articles in this issue address the scope of the chronic disease problem; the value, benefits and limitations of disease prevention and prevention programs, and a current state assessment of disease management and chronic care improvement.

One article by Thomas Bodenheimer, MD, Ellen Chen, MD, and Heather Bennett, MD, all with the University of California, San Francisco, Department of Family and Community Medicine, addresses the topic of health care workforce readiness. These authors conclude that the US workforce, as currently constituted, is not prepared to address the chronic disease burden. They also discuss three future options or scenarios for improving chronic care. The first option is chronic care improvement led by specialist physicians. Given workforce shortages among primary care physicians, advanced practice nurses and physician assistants, some envision physician specialists playing an even greater role in chronic care improvement. While specialists are uniquely positioned to care for specific chronic diseases, these writers view this scenario as undesirable, given that it could deprive patients of a personal primary care provider to coordinate and oversee care. Additionally, this option would likely drive service fragmentation and unsustainable chronic care costs. A second scenario would feature physician-led primary care. While an improvement, these writers cite evidence that primary care physician settings are not currently well-prepared or positioned to lead chronic care improvement. They note that primary care physicians simply do not have the time required to deliver all the required evidence-based care for their patients with chronic diseases. They also cite evidence that 50% of patients continue to leave primary care visits not understanding what they are told by primary care physicians and participate in clinical decisions only 9% of the time.1 The physician-led primary care scenario would require a significant reconfiguration of the existing primary care system, incorporating new patient partnering and shared decision-making steps, true multidisciplinary teams, and stronger public health connections according to these authors. A third scenario would feature multidisciplinary teams in integrated primary care and public health settings who are specifically configured and prepared to support patient shared decision-making, adherence, disease prevention and chronic care improvement—and reduce health care disparities and improve cultural competence. The authors site compelling evidence that integrated teams including physicians (and frequently geriatricians), nurses and other providers represent the best solution. At Kaiser Permanente, for example, medical assistants (who receive special training in panel management) capably review chronic disease registries, contact patients who need overdue services, and help physicians "intensify medications more rapidly." In other settings, nurse-led programs have used Bodenheimer's planned care model with excellent results.

The January/February Edition of Health Affairs, as well as an abstract of the Bodenheimer, et al. study can be accessed at http://content.healthaffairs.org. Please note that subscription is required for full text access.

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