It is expected that most priority conditions will be strongly related to chronic conditions. As discussed in Chapter 1, care for people with chronic conditions represents an increasing portion of health care resources in the United States. Four chronic conditions (cardiovascular disease, cancer, chronic obstructive pulmonary disease, and diabetes) account for almost three-quarters of all deaths in the United States (Centers for Disease Control and Prevention, 1999). Compared with people with acute conditions, the annual medical costs per person were more than double for people with one chronic condition and almost six times higher for people with two or more chronic conditions¹ (The Robert Wood Johnson Foundation, 1996). A study in one health maintenance organization found that 38 percent of enrollees had at least one chronic condition, and their costs averaged twice those of people with no chronic condition (Fishman et al., 1997). A study at another health maintenance organization found that 78 percent of direct medical costs were attributable to just 25 acute and chronic conditions and that three cardiovascular conditions (ischemic heart disease, hypertension, and congestive heart failure) accounted for 17 percent of those costs (Ray et al., 2000). It has been estimated that the top 1 percent of spenders account for 30 percent of health spending, whereas the bottom 50 percent account for only 3 percent of spending (Berk and Monheit, 1992). Given this concentration, the majority of health services utilized can potentially be associated with a definable list of conditions.

Yet the health care system is not well designed to meet the needs of the chronically ill. The current delivery system responds primarily to acute and urgent health problems, emphasizing diagnosis, ruling out serious conditions, and relieving symptoms (Wagner et al., 1996b). Those with chronic conditions are better served by a systematic approach that emphasizes self-management, care planning with a multidisciplinary team, and ongoing assessment and follow-up (Wagner et al., 1996a). As noted in Chapter 1, successful chronic disease management programs:

• Use a protocol or plan that provides an explicit statement of what needs to be done for patients, at what intervals, and by whom, and that considers the needs of all patients with specific clinical features and how their needs can be met. The care plan is a tool that links the multiple visits and contacts that characterize care for chronic illness.

• Redesign practice to incorporate regular patient contact, collection of critical data on health and disease status, and strategies to meet the educational and psychosocial needs of patients who may need to make lifestyle and other changes to manage their disease. Regular follow-up is a hallmark of the design of successful programs.