We live in a world dominated by chronic disease but continue to practice as if we are still dealing with acute illnesses. Anyone who works with arthritis patients can tell you the current system does not work. We reward the wrong things. We look for quick fixes and believe in false promises. We invest in the wrong technology. Moving to a system better suited to chronic disease care requires significant changes in thinking.1,2

The idea of prevention needs to be recast in terms of preventing the occurrence of expensive and disruptive exacerbations. Good care prevents the transition from impairment to disability and from disability to handicap. In the context of chronic diseases, the most preventable event is iatrogenic disease.

We must reexamine how we spend our time with patients. The heart of chronic disease management, as with geriatrics, is the principle of investing upfront with the expectation of recouping the investment with better results in the future. The current payment system does not support this approach. The idea of ordering patients to return for scheduled appointments should give way to an approach in which we see patients when their condition changes rather than just arbitrarily. Visits should be long enough to allow for an adequate assessment of the causes for the change in status. Patients staying the course need only short contacts, which can often be handled by other health care professionals. We must reexamine professional roles. Much of what has routinely been done by primary care physicians can be performed by nurse practitioners.3

Meaningful, active patient participation in their care is critical to chronic disease management. The efforts to empower patients have been encouraging but we need to form real partnerships between patients and clinicians.4 We need to teach patients how to make relevant observations of their status and what to do when the situation changes.



Accountability in chronic care must be expressed as the difference between actual and expected results. Unfortunately, the expected course is rarely shown. Accordingly, all one sees is a decline in the face of good care. Systems for showing the true benefit (expressed by this difference) are critical to developing support for investing in better chronic care.

Information systems are the critical technology for chronic disease care. We need to develop ways to deliver relevant information in a way that gets the attention of care providers. The current electronic medical record is not up to the task. We need an information system that is more structured and proactive.

Clinicians in medical care and long-term care need to agree on shared goals and communicate effectively. Most people are receiving long-term care because of serious underlying medical problems but long-term care means more than just attending to illnesses.

We must do more to bring the health care system into alignment with the epidemiological reality of chronic illness. Clinicians working in arthritis and rheumatology should be leading the charge. Randomized trials point to better ways to deliver chronic care.5 We typically think that better payment will solve the problem. Indeed, we worry about financing before we have a product worth buying. Changing the payment system is necessary but not sufficient. First, we must fix the infrastructure. Payment reform should reinforce the needed changes but will not bring them about on its own.