Chronic physical and mental conditions accounted for 47% of the global burden of disease in 2002. This disease burden is projected to increase to 60% by the year 2020; heart disease, stroke, depression, and cancer will be the largest contributors (Epping-Jordan et al., 2004). Earlier reports indicated that chronic diseases are responsible for more than 24 million deaths a year, or about half of the global total (World Health Organization, 1997). The leading causes are circulatory diseases, including heart disease and stroke; cancer; and COPD. As life expectancy in developing countries continues to increase--global life expectancy at birth reached 65 years in 1996--an aging population will begin to experience chronic diseases and conditions. The situation is referred to as epidemiology transition--the changing pattern of health in which poor countries inherit the problems of the rich, including not merely illness but also the harmful effects of tobacco; alcohol and drug abuse; and accidents, suicide, and violence. More often, however, the phenomenon is referred to as the double burden because of the continuing weight of endemic infectious diseases along with chronic illness. The term is equally applicable when used to describe the double burden in developed countries that must cope with the increased prevalence of chronic illness and soaring health care costs (Creer & Holroyd, 2006).

Reviews of health care in the United States often begin by citing data on health care costs. The practice may appear to relegate patients to a secondary position, but this is not the case: as is becoming increasingly clear, health care costs provide the context which must frame any approach to patient treatment. Beyond costs, the focus shifts towards targeting the key chronic disorders that need to be addressed, as well as how to do so, within the U.S.

I.HEALTH CARE COSTS

We spend more money in the U.S. on health care than any other nation--well over twice the per capita average among industrialized nations (Davis, 2005). Health expenditures have grown from $1.3 trillion in 2000 to $1.7 trillion in 2003, thus increasing the portion of gross domestic product attributed to the health sector from 13.3 percent to 15.3 percent (Levit et al., 2004). By 2014, total health spending is projected to constitute 18.7 percent of gross domestic product, up from 15.3 percent in 2003 (Hefler et al., 2004). A torrent of data makes it increasingly clear that we are not buying the best possible care with our money. Salient snippets of the failure of health care in the U.S. include:
• The Organization for Economic Cooperation and Development (OECD) track trends
among 30 industrialized countries. Recent data found that U.S. citizens spent $5,267 per capita for health care in 2002--53 percent more than any other country. Two possible reasons for the differential are supply constraints that create waiting lists in other countries and the level of malpractice litigation and defensive medicine in the United States. Services that typically have queues in other countries account for only three percent of U.S. health spending. The authors were surprised to find that despite the lack of waiting lists, Americans do not have access to a greater supply of health care resources than people in most other OECD countries. The cost of
defending U.S. malpractice claims is estimated at $6.5 billion in 2001, only 0.46 percent of total health spending. The authors found that while the U.S. had 50 percent more malpractice claims per 1,000 population than the U.K. and Australia and 350 percent more than Canada, payments were lower, on average, than those in Canada and the U.K. (this finding also suggests that more frivolous malpractice suits are filed in the U.S.). The two most important reasons for higher U.S. spending appear to be higher incomes and higher medical care prices (Anderson et al., 2005).
• Lack of health insurance remains a significant problem: between 2000 and 2003, the number of uninsured Americans grew from 39.8 million to 45.0 million, a 14 percent increase that fell hardest on working adults (U.S. Census Bureau, 2004). Health insurance premiums rose at double-digit rates each year over the same period (Gabel et al., 2004). The good news is that premiums rose 9.2 percent, the first year of single-digit increases since 2000; the bad news is that the percentage of firms offering health benefits has fallen from 69 percent in 2000 to 60 percent
in 2005 (Gabel et al., 2005). Insurance coverage is a reliable condition for many people in the U.S. An analysis of 1998-2000 health insurance data from the Medical Expenditure Panel Survey found large numbers of people with unstable health insurance coverage. Young adults, Hispanics, people with low levels of education, those who transition into and out of poverty, and those with private non-group insurance are most likely to have unstable coverage. In addition, demographic factors and type of insurance interact to determine stability of coverage. Young adults and Hispanics with Medicaid or private insurance, for example, were more likely to lose their coverage. Furthermore, less than half of people who transitioned into and out of low income and were initially uninsured were able to obtain coverage (Klein, Glied, & Ferry, 2005).
• An analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey found an estimated 77 million Americans age 19 and older--nearly two of five (37%) adults--have difficulty paying medical bills, owe money on medical debt, or experience both. Working-age adults incur significantly higher rates of medical bill and debt problems than adults 65 and older, with rates highest among the uninsured. Even working-age adults who are continually insured have problems paying their medical bills and have accrued medical debt. Unpaid medical bills
and medical debt can limit access to health care: two-thirds of people with a medical bill or debt went without needed care because of cost--nearly three times the rate of those without these financial problems (Doty, Edwards & Holmgrom, 2005)
• Health care for people with chronic diseases accounts for 75% of the nation’s total
health care costs (Centers for Disease Control, 2004).

II. CHRONIC ILLNESS

One hundred million people in the U.S. have at least one chronic condition, with more than half having more than one chronic illness. Eighty-eight percent of people aged 65 years or older have one or more chronic illness, and one quarter these have four or more conditions (Bodenheimer, Wagner & Grumbach, 2002). Snapshots of the impact of chronic illness include:
• Chronic diseases, particularly heart disease, cancer, and diabetes, are the leading causes of disability and death in the United States. Each year, chronic diseases claim the lives of more than 1.7 million Americans. These diseases are responsible for 7 of every 10 deaths in the U.S. Chronic diseases cause major limitations in daily living for more than 1 in every 10 Americans, or 25 million people (Centers for Disease Control, 2004).
• Five chronic diseases--heart disease, cancer, stroke, chronic obstructive pulmonary diseases (COPD), and diabetes--account for more than two-thirds of all deaths in the United States; combined, heart disease, cancer and stroke together account for almost 60% of all deaths in the United States.
• Chronic lower respiratory disease, which includes bronchitis, emphysema, asthma, and chronic airway obstruction, is the fourth most common cause of death; diabetes is the sixth most common.
• Kidney diseases, particularly nephritis and nephrosis, are the ninth leading cause of death.

Information summarized by the Centers of Disease Control regarding specific chronic diseases revealed:
A. All Cancers
• Almost one in every four deaths in the U.S. results from cancer; it was estimated that 563,700 Americans would die of cancer in 2004. Cancer is the second most common cause of death in the United States (Centers for Disease Control, 2004).
• A total of 1,372,910 new cancer cases and 570,280 deaths are expected in the United States in 2005. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for persons younger than 85 since 1999 (Jemel et al., 2005).
• In 2003, cancer cost the nation $189.5 billion in health care expenditures and lost productivity (Centers for Disease Control, 2004).
B. Arthritis
• There are an estimated 42.7 million Americans with arthritis. Osteoarthritis
is the most prevalent form of the disease, affecting over 20 million people. More than half of all people age 65 and over have symptoms of osteoarthritis; it is the leading cause of disability in this age group.
• With the aging of the U.S. population, the prevalence of arthritis is expected to increase in the coming decades. By the year 2030, an estimated one quarter of the projected total adult population or 64.9 million adults aged 18 years and older will have doctor-diagnosed arthritis, compared to the 42.7 million adults in 2002. Two-thirds of those with arthritis will be women. These estimates may be conservative, as they do not account for obesity-related arthritis.
• Obesity is a known risk factor for the development and progression of knee osteoarthritis and possibly osteoarthritis of other joints. For example, obese adults are up to 4 times more likely to develop knee osteoarthritis than normal weight adults.
• The impact of arthritis on individuals is significant. Almost 38% (16 million) of the
42.7 million adults with doctor-diagnosed arthritis report limitations in their usual activities due to arthritis. In addition to activity limitations, 31% (8.2 million) of working age adults with doctor-diagnosed arthritis report limitations in work activities because of arthritis.
• Functional limitation in common daily activities is frequent among adults with arthritis: 40% report it is “very difficult” or they “cannot do” at least 1 of 9 important daily functional activities, such as sitting, reaching, grasping, etc. Despite the fact that physical activity and exercise have been shown to benefit people with arthritis by improving pain, function and mental health, many people with arthritis report no leisure time physical activity. Almost 43% of adults with doctor-diagnosed arthritis report no leisure time physical activity, which is higher compared to 35% of adults without arthritis (Centers for Disease Control, 2002).
C. Asthma
• In 2002, 30.8 million Americans had been diagnosed with asthma sometime during their lifetime. Among adults, 21.9 million had received the diagnosis compared to 8.9 million of children.
• Among racial and ethnic groups, Puerto Ricans have the highest rate of lifetime asthma and Mexicans the lowest.
• About 60% of the people surveyed had had an asthma attack in the previous year. Among those who experienced an attack, children 5-17 years of age missed 14.7 million school days due to asthma; adults aged 18 years and over who were currently employed missed 11.8 million work days due to asthma.
• In 2002, there were 13.9 million outpatient asthma visits to private physicians offices and hospital outpatient departments. Blacks had an outpatient visit rate about the same as whites, while females had a 50% higher outpatient visit rate compared to males. There were 1.9 million visits to emergency departments for asthma in 2002.
• There were 4,261 people who died from asthma in 2002 (Centers for Disease Control, 2003).
D. Diabetes
• About 18 million people in the U.S. have diabetes, and over 5 million of these people are unaware that they have the disease. One in three Americans born in 2000 will develop diabetes during their lifetime.
• Each year, an estimated 12 to 24 thousand people become blind because of diabetes. In addition, nearly 43,000 people with diabetes begin treatment for kidney failure each year, and approximately 82,000 undergo diabetes-related lower extremity amputations.
• In 2001, diabetes was the sixth leading cause of death. Diabetes, however, is believed to be underreported on death certificates.
• The direct and indirect costs of diabetes in the U.S. totaled $132 billion in 2002.
E. Heart Disease
• Heart disease killed more than 700,000 Americans in 2001, thus accounting for 29% of all deaths in the U.S.
• In 2001, the rate of death from heart disease was 31% higher among blacks than whites, and 49% higher among men than women.
• About 66% of heart attack patients do not make a complete recovery; approximately
42% of people who experience a heart attack in a given year will die from it.
• In 2001, heart disease cost the nation $193.8 billion.
F. Overweight and Obesity
• Obesity has more than doubled in the U.S. in the past two decade. In 2002, 59% of American adults were overweight on the basis of self-reported weight and height. Men were more likely than women to be overweight (67% vs. 51%) on the basis of self-reported weight and height.
• People who are overweight (body mass index [BMI]≥25) or obese (BMI≥30) are at increased risk for heart disease, high blood pressure, diabetes, arthritis-related disabilities, some cancers, and possibly asthma.
• In 2000, the direct and indirect cost attributable to obesity in the U.S. was $117 billion.
F. Stroke
• Each year, about 700,000 Americans have a stroke. On average, a stroke occurs every 45 seconds.
• In 2001, stroke accounted for more than 163,500 deaths; it is the third leading cause of death and a major cause of disability in the United States.
• In 2001, rates of death from stoke were 43% higher among blacks than whites; each year, about 400,000 more women than men suffer a stroke.

III. HEALTH CARE FOR CHRONIC ILLNESS IN THE U.S.

While the double burden of higher costs and increasing prevalence of chronic diseases has been taking place, various ways to treat the illnesses have been suggested. Attempting to keep up with all the proposed strategies and schemes requires learning to distinguish one term from another and undergoing a veritable baptism by alphabet soup to understand the various acronyms that are constantly emerging. The list of terms used to describe health care requires a glossary compiled and updated by the National Institutes of Health (available online at http://aspe.os.dhhs.gov). Despite contradictions among the terms, an effort has been made to shoe horn different strategies under the terms managed care. A brief review is offered as a refresher, particularly with respect to the acronyms.
A. Managed Health Care
Managed health care is a system that controls the financing and delivery of health services to members who are enrolled in a specific type of healthcare plan. Goals of managed health care are to ensure that: (a) providers deliver high-quality care in an environment that manages or controls costs; (b) the care delivered is medically necessary and appropriate for the patient’s condition; (c) care is rendered by the most appropriate provider; and (d) care is rendered in the most appropriate, least-restrictive setting. As to whether managed care achieves these goals is debatable, a result that will be addressed later. Much of what is considered as managed care involves three types of managed care plans, each with distinctive features or characteristics, and each recognized more by the acronym than by the term for which it stands.
1. Health Maintenance Organizations (HMO)
An HMO enters into contractual arrangements with healthcare providers (e.g., physicians, hospitals and other healthcare professionals) who together form a “provider network.” Simply put, a contracted provider is one who provides services to health plan members at discounted rates in exchange for receiving health plan referrals.
• Members are required to see only providers within this network to have their healthcare paid for by the HMO. If the member receives care from a provider who isn’t in the network, the HMO won’t pay for care unless it was pre-authorized by the HMO or deemed an emergency.
• Members select a Primary Care Physician (PCP), often called a “gatekeeper,” who provides, arranges, coordinates, and authorizes all aspects of the member’s health care. PCPs are usually family doctors, internal medicine doctors, general practitioners and obstetricians/gynecologists.
• Members can only see a specialist (e.g., cardiologist, dermatologist, rheumatologist) if this is authorized by the PCP. If the member sees a specialist without a referral, the HMO won’t pay for the care.
• HMOs are the most restrictive type of health plan because they give members the least choice in selecting a health care provider. However, HMOs typically provide members with a greater range of health benefits for the lowest out-of-pocket costs, such as either no or a very low co-payment (the amount of money a member is required to pay the provider in addition to what the HMO pays. It often must be paid prior to services being rendered).
2. Preferred Provider Organizations (PPO)
PPOs are similar to HMOs in that they enter into contractual arrangements with healthcare providers (e.g., physicians, hospitals and other healthcare professionals) who together form a “provider network.”
• Unlike an HMO, members don’t have a PCP (“gatekeeper”) nor do they have to use an in-network provider for their care. However, PPOs offer members "richer" benefits as financial incentives to use network providers. The incentives may include lower deductibles, lower co-payments, and higher reimbursements. For example, if you see an in-network family physician for a routine visit, you may only have a small co-payment or deductible. If you see a non-network family physician for a routine visit, you may have to pay as much as 50 percent of the total bill.
• PPO members typically don’t have to get a referral to see a specialist. However, as mentioned above, there’s a financial incentive to use a specialist on the PPO’s provider network.
• PPOs are less restrictive than HMOs in the choice of health care provider. However,
they tend to require greater "out-of-pocket" payments from the members.
3. Point-Of-Service Plans (POS)
A POS plan is often called an HMO/PPO hybrid or an “open-ended” HMO. The reason it’s called “point-of-service” is that members choose which option – HMO or PPO – they will use each time they seek health care.
• Like an HMO and a PPO, a POS plan has a contracted provider network.
• POS plans encourage, but don’t require, members to choose a primary care physician (PCP). As in a traditional HMO, the PCP acts as a “gatekeeper” when making referrals. Members who choose not to use their PCPs for referrals (but still seek care from an in-network provider) still receive benefits but will pay higher co pays and/or deductibles than members who
use their PCPs.
• POS members may also opt to visit an out-of-network provider at their discretion. If so, a member co pays, and insurance and deductibles are substantially higher.
• POS plans are becoming more popular because they offer more flexibility and freedom of choice than standard HMOs.
These three options (or acronyms) are likely the most familiar to readers. There have, however, been types of managed care strategies proposed for the care of chronic illness.
3. Disease Management
In analyzing the literature on disease management programs for the Congressional Budget Office, Holtz-Eakin (2004) pointed out that in the past decade many health plans and organizations have begun to offer a new model of care for chronically ill patients--disease management--in an attempt both to improve the quality of care that enrollees receive and to slow the growth of their health care costs. The term "disease management" covers a range of activities that address several perceived shortcomings of current medical practice. First, chronic conditions often go untreated or are poorly controlled until more serious and acute complications arise. Second, as reported by the Institute of Medicine, a large gap often exists between evidence-based treatment guidelines (what medical research has shown to be the most effective protocols for treating specific diseases) and current practice. Third, patients often receive care for a disease from many different physicians or providers and frequently are called upon to monitor, coordinate, or carry out their own treatment plan--with limited ability to do so. Through a combination of: (a) enhanced screening, monitoring, and education; (b) the coordination of care among providers and settings; and (c) the use of best medical practices, disease management seeks to identify chronic conditions more quickly, treat them more effectively, and thereby slow the progression of those diseases. The presumption is that better care today will mean better health and, perhaps, less expensive care tomorrow. Until recently, care management differentiated two general approaches: disease management, which targeted individuals diagnosed with specific conditions, such as diabetes or congestive heart failure, and case management, which focused on high-risk patients with complex combinations of medical conditions and which was often triggered by an acute event such as hospital admission. The former often involved applying standardized techniques in a systematic way, while the latter was seen to require a treatment plan tailored to each patient's unique circumstances. The distinction between the two approaches has become blurred, however, as disease management firms have adopted broader and more-comprehensive approaches. Disease management programs are rapidly expanding services and now typically assume responsibility for coordinating care for the range of chronic conditions that a patient may experience.
Two disease management models for providing health care to chronically-ill patients have emerged in the past decade: the chronic care model and the self-management model. Bodenheimer, Lorig, Holman, and Grumbach (2002) suggest the models are poles on a spectrum rather than wholly distinct concepts. However, deep divisions exist between the two approaches. The gap can be illustrated by describing each approach.
Chronic Care Model (CCM)
The CCM is a systems approach to the management of chronic disorders. If the system is built, it can provide effective treatment. The CCM is an evidence-based, conceptual managed care framework proposed by Wagner and colleagues (Wagner et al., 1996; Von Korff et al., 1997). The model describes a health care system to assist medical practices—particularly those in primary care settings—to improve outcomes among patients with chronic illness. The changes support the development of informed activated patients and proactive healthcare teams to manage chronic disease. Epping-Jordan and colleagues (2004) reported that the CCM has guided a number of American health care organizations to improve their efforts in caring for chronic illness. To date, they continued, over 1,000 health care organizations, including approximately 500 community health centers supported by the Health Resources Services Association’s Bureau of Primary Health Care, have participated in healthcare improvement activities using the CCM framework. Most of these organizations have made measurable improvements in the quality of their care.
The CCM consists of four interacting components or systems of support:
• Self-management support. According to Jordan and colleagues (2004), self-management support involves providing information and support to enable patients (and families) to care better for their illness. This support is central to improving care and outcomes. Successful self-management support can be effectively delivered in "stand alone" programs but, according to the authors, evidence suggests that long-term benefits may require an ongoing collaborative process between patients and professionals (the latter point is not supported by the evidence, however). In the CCM model, self-management replaces the term, “patient-centered health care.” Proponents of the model are less interested in having patients as equal partners in controlling a chronic illness than in maintaining what they perceive as control over patient behavior, a vestige left over from the Oslerian tradition of medical management (Creer & Holroyd, 2006). In short, these writers advocate what is an oxymoron, “guided self-management.” Patients need to be taught what skills to perform, but the medical team does not limit their autonomy or ingenuity. • Delivery system design. Usual health care systems oriented to address acute illness make it difficult for productive interactions to occur. An Institute of Medicine report argued that adding greater expectations or simple solutions to systems designed for a different set of healthcare problems is unlikely to be successful. The system must change, and this is reflected in delivery system design. For example, productive interactions are made more likely by planning visits or other interactions in advance. Non-physician members of a practice team are crucial to effective care of chronic illness, but they need clear complementary roles. Patients with more complex conditions and/or care needs often benefit from more intensive care from nurse care managers and outreach workers who provide close follow up and help to increase adherence.
• Decision support. Health care providers must have access to the expertise necessary to care for patients—decision support in the CCM. Evidence-based practice guidelines or protocols ensure that provider teams are aware of effective treatments, but this information must be integrated into the fabric of decision making—for example, reminders or standing orders—to have a meaningful impact on patient care. In addition to guidelines, practice teams must have access to professionals with clinical expertise and experience in the care of the condition.
• Clinical information systems. Clinical information systems provide timely data about individual patients and populations of patients. Whether computerized or hand written, information systems are critical for effective chronic condition programs. A database that includes information about the process and results of care for all patients is the essential ingredient. Healthcare teams with access to a registry can contact patients with specific needs, deliver planned care, receive feedback on their team’s performance, and benefit from reminder systems.
Epping-Jordan and colleagues (2004) concluded by noting that improvement in the care of patients with chronic illness through adoption of the CCM will only occur if system leaders, whether private or governmental, make it a priority and provide the leadership, incentives, and resources necessary to make improvements happen. A primary limiting factor to a general adoption of the model in the U.S., however, is the overall fragmentation of health services and the lack of clear policy directions for the management of chronic conditions. So, while many healthcare organizations have implemented aspects of the CCM, these changes have not extended to the wider population due to the lack of broader based political, financial, and community support.
2. Self-Management Model
Bodenheimer, Lorig, Holman, and Grumbach (2002) asserted patients with chronic conditions make decisions and perform most of the actions required in the day-to-day management of their illnesses. They noted, “This reality introduces a new chronic disease paradigm: the patient-professional partnership, involving collaborative care and self-management education. Self-management education complements traditional patient education in supporting patients to live the best possible quality of life with their chronic condition. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy--confidence to carry out a behavior necessary to reach a desired goal. Self-efficacy is enhanced when patients succeed in solving patient-identified problems. Evidence from controlled clinical trials suggests that (1) programs teaching self-management skills are more effective than information-only patient education in improving clinical outcomes; (2) in some circumstances, self-management education improves outcomes and can reduce costs for arthritis and probably for adult asthma patients; and (3) in initial studies, a self-management education program bringing together patients with a variety of chronic conditions may improve outcomes and reduce costs. Self-management education for chronic illness may soon become an integral part of high-quality primary care. but not because they are incorporated into a single model; rather, evidence obtained with each component can be judged by its own merit. There is, for example, considerable evidence to support the value of self-management techniques; decision support, especially the use of treatment guidelines; and improved clinical information systems. The data suggests that with the exception of managed care organizations, the need to totally revamp a delivery system for health care, the most far-reaching component to implement, is problematic at best and unlikely at worst” (p. 2469). This is a succinct summary of self-management in health care for chronically ill patients.
3.Comparison of Chronic Care and Self-management Model
• The CCM does not embrace the position that patients are in charge of their own treatment of a chronic condition; rather, it asserts that health care system that is under the control of medical personnel. It is not a patient-centered approach, as proponents of the approach readily admit, but an extension of the authoritarian treatment model so prevalent in health care in the 20th century. The self-management model is based on the reality that patients perform the daily tasks needed to manage their chronic conditions, both with and without medical advice. As individuals are autonomous to begin with, self-management training is aimed at teaching them to become health partners with medical personnel to improve overall control of a chronic illness (Creer&Holroyd, 2006).
• The CCM insists that the health delivery system must be overhauled in order to accommodate the needs of chronically ill patients is unrealistic. This is not about to occur. As Bodenheimer et al. (2002) pointed out, however, the need to totally revamp a delivery system for health care is problematic at best and unlikely at worst. The self-management model is practical in assuming that the need is now for assisting chronically ill patients and their families to manage their conditions.
• The evidence on cost savings from disease management approaches, including the CCM, is limited. Moreover, many available studies that address the effect of disease management programs on health care expenditures have methodological limitations. As one reviewer of the literature on disease management has noted, the "lack of a consistent analytic framework has made comparisons of reported results impossible and has rendered many reports unreliable. The field particularly needs measurement standards for evaluating economic results" (Holtz-Eakin, 2004). Improving health outcomes and mitigating health care costs do not necessarily go hand in hand and disease management programs may be a worthwhile investment even if they do not reduce overall health care spending. This point is debatable. Health care expenses must be reduced or contained with application of any disease management program. Equally important, the health care and quality of life must occur in chronically ill patients exposed to any such program. If these two conditions are not met, any disease management efforts are a drain on finite economic resources. Given the Congressional Budget Office's (CBO's) focus on budgetary effects, the agency's analysis has centered on the questions of whether those programs have been effective in reducing health care costs and how such programs might apply to Medicare.
• Results are mixed and do not provide a firm basis for concluding that disease management programs reduce total costs. Although there are cases of clinical and economic improvements by specific disease management programs for particular groups of patients, whether those results could be achieved for broader populations of patients is unclear. These statements would include both application of the CCM and self-management models. However, there is solid support to indicate that self-management is effective for such disorders as arthritis, asthma, diabetes, and heart disease (e.g., Bodenheimer et al., 2002).
• Decision support, as described in the CCM, is directed only at health care personnel. Much of what is described is already in place, e.g., treatment guidelines that were introduced without a mammoth reshaping of the health care system. Proponents of the CCM, however, add nothing about decision making by patients, an omission that is likely due to their not perceiving patients as health care partners. Yet, as patients do make most of the decisions regarding their own health, including whether or not to adhere to medication instructions, more attention should be paid to the strategies they use regarding their decisions and subsequent behaviors. There is information suggesting patients can become very sophisticated decision makers regarding their own health (Creer, 1990; 2005; Creer, Caplin & Holroyd, 2005).

IV. WILL HEALTH CARE CHANGE IN THE U.S.?

Numerous papers and books describe what is wrong with health care in the U.S. All cite reasons why, despite all the money that is spent on health care, we lag behind many other developed countries with respect to providing health care to our citizens. A few reviewers have concluded that we have no health care system per se in the United States, although the majority of observers are seemingly unaware of this de facto state. If there were an admission that no health care system exists, then there would be nothing to fix. An example of the reticence to admit they may not be a health care system in an otherwise thorough discussion of health care by Geyman (2002). He advocated how the health care system can be fixed, although he could not refrain from displaying his skepticism by referring, in parentheses, to a “system.” Perhaps John Kleinke (2001) is the only one who correctly diagnosed the matter by pointing out that a health care system in the U.S. is a myth; it simply does not exist.
The conclusion Kleinke reached should not surprise anyone, particularly if we recall what occurred during the flu season of 2004-2005. The season started with the public being alerted to the possibility that we could have a flu epidemic, a warning coupled with repeated urging to obtain a flu shot. This prompted many people, particularly older adults with chronic ailments, to seek immunization for flu. When they visited their doctor’s office or public clinic, however, they were told that there was a shortage of flu vaccine in the U.S. Only those with chronic illnesses were given shots on what was a decidedly hit-or-miss basis. By the time the vaccine did become available, the flu season was almost over and, fortunately, unaccompanied by an epidemic. By this time, however, any interest in obtaining a flu shot had long dissipated. To believe this particular problem has been remedied by creating or tweaking a supposed health care system to manage future emergencies is nonsense: concern about a potential pandemic of Avian flu was met by a government response to send out the troops, not by a strategy to quickly identify the strain, develop a vaccine, manufacture the vaccine, and dispense it to all citizens of the U.S. As an editorial in the New York Times noted, proposals on managing epidemics and pandemics are substantive, but short on practicality.
Solutions to the problem of health care in the U.S. often center on the development of an entirely new health care system. A number of major revisions to health care in the United States have been proposed, most notably the Clinton Health Plan. These plans are anchored by proposing a single-payer national health program. In addition, a number of different suggestions have been offered that share a commonality of being long on generalities but short on specifics. The result is often a highly complex and intricate paradigm that only Rube Goldberg would understand. Illustrative of such a plan is the flow chart depicting the Clinton Health Plan (Fischer, 1993). It is not that the plan lacks logic or rationality; rather, it is that it reflects linear thinking taken to its nth degree and is, therefore, devoid of imagination. Other suggestions for health care reform are often tacked onto any proposals for health care: Geyman (2002), for example, proposed a number including:
• Adopting campaign finance reform to limit special interests in reforming health care in the U.S.;
• Expanding a well-financed public health sector: (a) to support medical education and research; and (b) to set high standards for quality of care;
• Building coalitions among stakeholders of health care;
• Implementing tort reform; and
• Increasing public education.
It can be argued that each of these proposals has merit in its own right. To imply, however, that they are necessary in order to provide effective and economical health care to citizens currently needing such services in the U.S. is totally unrealistic. Three scenarios regarding health care-- designated as stormy weather, the long and winding road, and the sunny side of the street--contained in Health and Health Care, 2010 (Institute for the Future, 2000), suggests we are dead stuck on stormy weather. The scenario is unlikely to change; despite all the changes that have occurred with managed care, Oberlander (2002) concluded that the U.S. appears no closer to solving the problems that have characterized health care in the U.S. for the past three decades. His conclusions, however, are positively rosy compared to Fuchs and Emanual (2005). They pointed out that while dissatisfaction with the U.S. health care system is widespread, no consensus has emerged as to how to reform it. Fuchs and Emanual considered several solutions, but concluded that over the long term, reform is likely to come only in response to a major war, depression, or large-scale civil unrest. Thus, the answer to the question asked at the outset of this
section is a resounding “no.”

V. WHAT CAN BE DONE FOR THE CHRONICALLY ILL?

As no new system of health care is apt to emerge in the U.S., the need is to focus on what can be done here and now for chronic illnesses within the context of health care as it currently exists. This is the major challenge to health in the 21st Century. To answer the challenge, a number of issues must be addressed. Prominent among these include:
• Patient changes. Controlling chronic disorders requires that patients provide the daily actions required to manage their condition (Holman, 2004; Creer & Holroyd, 2006). The aim is to create a knowledgeable and empowered health partner, not just a compliant patient (I prefer the term “health partner” to “patient” as it best conveys the role those afflicted by chronic diseases should play; in addition, it reflects that it is just not the management of a chronic illness that is important, but the overall health of the individual). There are two conceptual issues here (Glasgow et al., 2001): First, although health care providers can provide helpful recommendations, advice, and counseling, it is the patient alone who decides what strategies to put into practice and to experience the consequences--both positive and negative--of self-management actions. Patients control their chronic illness, which may entail their changing their provider’s recommendations after leaving a doctor’s office. We found, for example, that patients often do not follow an action plan, even if developed jointly with their physician, to control asthma attacks (Creer et al., 1988; Creer, Caplin & Holroyd, 2005). Overall, the results were likely better than would occur if the patients blindly followed the action plan. Second, recognition of the role of patients negates the concept of patient adherence or compliance and shifts the focus towards the patient-provider relationship. Increasing evidence indicates that shared decision-making interactions centered on patient concerns are more effective than the authoritarian relationship where the provider does all the advising (Glasgow et al., 2001).
• Physician changes. Physicians must be trained to modify their consultation model in response to patient need (Cassel, 1997; Holman, 2004). Holman described the failure of medical education and, more generally, the health care system to adapt to two interrelated changes in the past 50 years: (a) the replacement of acute disease by chronic illness as the dominant health problem; and (b) the resultant need to change the role the patient plays in managing disease. Despite the need to be flexible and adapt elements from the authoritarian and shared decision-making models to fit a different clinical situations, too many physicians and patients yearn to keep the authoritarian model of providing health care. Druss (2004), for example, waxed nostalgically in comparing his practice of medicine today with his father's practice of medicine a half a century ago. The comparison between medicine 50 years ago versus today is like comparing apples and oranges. There is a far more complex mosaic of illnesses and treatments today then there was yesterday. Furthermore, the context within which a physician practiced 50 years ago has changed with the shift in focus from acute to chronic diseases in the past few decades. Blame for the lack of motivation to acquire and perform self-management skills in order to be health partners often rests with patients themselves. For most of the 20th century, we were conditioned to see our physician for everything ranging from whether we should go on a diet to the brand of cough syrup to use. “Let the doc do it,” was a de facto mantra. Too many people appear unwilling to assume responsibility for their own health, a situation that must change.
• Primary physicians and specialists. To remedy the lack of an effective health care system, it has been recommended that care for chronically ill patients be shifted to specialists in disease management programs. As noted earlier, Wagner and his colleagues (1996) outlined a health care system based on the collaborative management of chronic illness. A component of the system would be instruction in self-management for patients to help them become health partners. There are several barriers to the implementation of collaborative disease management
programs, however.
•• First, such programs require a substantial renovation of the current health care system, a revamping that would require a major investment on the part of any nation. As argued throughout the paper, there is little chance that such a costly revamping will occur (Fuchs & Emanual, 2005).
•• Second, there are over a hundred million Americans who live with a chronic illness. The overwhelming majority of these patients receives the bulk of care in primary care practices and will do so for the foreseeable future. Coordination of care across clinicians and sites is a defining characteristic of primary care, particularly to patients with chronic disease, but this is often the exception rather than the rule. There are reports that primary care has fallen short in performance and in the eyes of consumers but, as admitted by Rothman and Wagner (2003), there is no evidence to indicate any clear superiority of the alternative systems to primary care. Until superiority is demonstrated, it is easy to see the hesitation to invest in other systems.
•• Finally, proposed collaborative health care systems avoid the stark reality of the problems they face. The problem was succinctly described in a review on the plight of Medicare in the U.S. (Anderson, 2005). When initially operationalized in 1966, the primary orientation of Medicare was the treatment of acute, episodic illness. This aim changed over time, particularly as patient’s present more than one chronic illness with the extension of their lives. Currently, a total of 83 percent of Medicare beneficiaries have at least one chronic condition, with expenditures and the probability of an adverse outcome increasing with the diagnosis of each additional disease. The problem facing Medicare in the US--likely similar to what is faced by universal health care plans in other developed nations--was summarized by Anderson, “Any policy maker who is considering the modernization of Medicare must recognize that the 23 percent of beneficiaries with five or more chronic conditions account for 68 percent of the program's spending. In addition, the treatment of these beneficiaries is likely to remain a high-cost item until they die, since every year they see an average of 13 physicians and fill an average of 50 prescriptions” (p. 305). A well-funded and organized universal health care system could deal with these patients, but the uncoordinated system in the U.S. cannot.
A flaw in the current system of health care centers on tensions between primary care physicians and specialists. When a primary care physician refers a patient to a specialist, he or she is often excluded in making decisions regarding the health partner’s future treatment plans. The alienation that occurs with exclusion not only increases the reluctance of many primary care physicians to refer patients to specialists, but also may result in conflicting advice and treatment regimens for the patients and the resulting errors that may occur as a consequence. Furthermore, the continuing relationship patients have with a personal physician, a factor that increases survival rates and lower health care costs, is undermined.

VI. THE SOLUTION TO IMPROVING HEALTH CARE FOR THE CHRONICALLY ILL?
UNIVERSAL SELF-MANAGEMENT TRAINING AND USE IN PRIMARY CARE

A number of reasons can be cited as to why self-management is the only solution to the problem of improving health care for chronically ill patients. Virtues of the approach include:
•• The approach fits the current health care modus operandi in the U.S. It can be introduced on a broad scale without a major renovation of whatever health care process is in place without incurring expense or disruption of service. This is in stark contrast to the Chronic Care Model that requires that conditions be favorable in all three “of the overlapping galaxies that effect health care institutions--the general community, the health care system, and the institution itself” (Bodenheimer, Wagner, & Grumbach, 2002, p. 1914). This alignment of galaxies is not predicted to occur.
•• Self-management instruction can readily occur in the offices of primary care physicians the way they are currently structured. As primary care physicians treat the bulk of patients with chronic illness in the U.S., this is a revolutionary and significant change for patients and primary care physicians alike. As primary care is equal to alternative approaches (Rothman & Wagner, 2003), the approach will permit the enhancement of primary care in the U.S.
•• The approach would use a generic model of self-management. This strategy offers a potentially effective way to coordinate treatment for health care partners who experience comorbid conditions. It should have considerable value, for example, in coordinating the treatment of Medicare beneficiaries with five or more conditions who see an average of nine physicians on an outpatient basis and four hospital-based physicians annually (Anderson, 2005). Primary care patients must coordinate the health needs of patients, a suggestion in line with those attempting to address the need for some kind of health care integration (Starfield et al., 2003).
•• The approach will exemplify optimal patient involvement as health partners in managing their condition. As patients with chronic illness solely make decisions and perform actions to control their condition, the approach is reality-based with respect to the contribution of individual partners.
•• The approach will produce strong health outcomes in an effective and efficient manner. This, after all, is the goal of health care.
•• The approach will reduce barriers to self-care with respect to the management of comorbid conditions such as knowledge of the different conditions and their treatment. It will also help control a number of prominent barriers specifically related to having multiple medical conditions. Self-management interventions can address interactions between chronic conditions as well as teach skills necessary to care for individual diseases (Bayliss, Steiner, Fernald, Crane, & Main, 2003).
•• Practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall (Oxtbye et al., 2005). The approach to be outlined will permit trained medical personnel, specifically nurses, to take over teaching self-management skills and free physicians to concentrate on medical aspects of chronic conditions. This change will permit the latter to treat their patients in a more effective and efficacious manner, often by serving as a more effective gatekeeper.
•• The approach would correct for deficiencies of health voiced by patients in six countries--Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States (Schoen et al., 2005). These include:
••• Provide better care by involving nurses more in treatment plans (self-management plans and involvement of nurses were associated with higher rates of adherence to care targets in all countries);
••• Provide effective communication between patients and their physicians, thus supporting more active involvement in care and the promotion of adherence;
••• Provide better coordination of care and information flow across sites of care which are instrumental for providing efficient and safe care (coordination gaps occurred most frequently in the U.S.);
••• Provide timely access and reduced financial burdens to patients (patients in Canada and U.S. were more apt to report the lack of rapid access to physicians and more likely to wait 6 days or longer for an appointment than patients in the other countries; as found in other surveys, the U.S. is an outlier for financial burdens on patients and patients forgoing care because of costs);
••• Provide better coordination of medication usage, particularly among patients in all countries who take multiple medications for comorbid conditions; and,
••• Provide better health care (sicker adults in Germany and the U.S. were the most negative across countries in complaining about the health care they obtain).
•• The approach will synthesize the key elements of what is known about the teaching and performance of self-management skills to control chronic disorders. This would involve the teaching, assessment of performance, and the maintenance of self-management skills over time. Key elements include:
••• Providing knowledge of their condition and treatment to most patients;
••• Teaching patients to gather, via self-monitoring, information regarding their condition. The step would also entail teaching patients how to record, interpret, and make decisions as to what to take based on the data;
••• Negotiating a contact within the primary care physician’s office to gather, review, and reinforce patients for gathering information on themselves; and
••• Utilizing the self-efficacy of patients in performing self-management skills to strengthen, refine, and maintain the skills they are taught. In reviewing the literature on maintenance of self-management for chronic illnesses, self-efficacy is paramount in insuring self-management skills are performed for periods ranging from two (e.g., Lorig et al., 2001; Lucas et al., 2001) to seven years (Caplin & Creer, 2001).
•• Optimize the skills of nurses in primary care offices. Primary care physicians constantly complain that they do not have the time to teach patients self-management skills. There is likely some justification for this complaint but, at the same time, it also provides a great excuse. Nurses are also busy, but they generally show a greater interest in patient-centered practices than their medical colleagues. A Cochrane Collaboration on diabetes concluded that nurses could play a significant role in patient-oriented interventions, including self-management, through patient education or facilitating adherence to treatment (Renders et al., 2001). Other reviews suggest that nurses play a large role in maximizing the care of patients (e.g., Infante et al., 2004), and others place nurses at the center of providing self-management training to patients (e.g., Kralik, Koch, Price & Howard, 2004). The program to be described achieves this goal.

VII. PROPOSED SELF-MANAGEMENT PROGRAM FOR PRIMARY CARE

The purpose of the proposed program is to teach patients the basics of self-management during routine visits to their primary care physician. In this way, they can become health partners in carrying for their health. The program will be designed within the following context:
• Primary care physicians face a harried schedule; this point cannot be denied. From the time they reach their office in the morning until they leave, they see a wide variety of patients with almost an infinite number of complaints. The physicians do an excellent job in attempting to manage the myriad array of medical and disease manifestations of the problems presented to them. Allied personnel, ranging from office staff to nurses, are also busy in helping the physician care for patients.
• On the surface, the context of the primary physician’s office appears to have few opportunities for instruction of patients. This is misleading, a fact that becomes apparent if one carefully examines the typical sequence of patient actions: (a) upon arriving at a physician’s office, patients checks in with a member of the office staff; (b) they then are told to wait for a variable period of time; (c) following a wait, they are taken into the sanctum of the nurses where information regarding why they are there, as well as data on vital signs or from other tests, is obtained; and (d) they are then relegated to an examination room to await the physician.
• It is in the examination room where a window of time for education occurs. There is usually a variable waiting period here, but it is almost always long enough to permit nurses to provide self-management training. Patients are alert and somewhat apprehensive; they are usually in a mood to learn. The format of such training must be short, lasting approximately 5 minutes, but take place each visit.
• The research my colleagues and I conducted has followed other self-management studies in looking at change that occurs as a result of introducing and assessing self-management in chronic diseases. This approach, referred to as Black Box research (Creer, 2005), relates input to output in a system by noting a formal description of the transformation rules that link the two, but without stating the nature of the process that occurs between input and output. Thus, patients taught asthma self-management skills to improve their asthma (input) can expect changes in different outcome measures of their condition (output). This finding relating input to output has been found in any number of investigations, including the research we’ve conducted.
• Where my colleagues and I have deviated from other self-management studies conducted across all chronic diseases has been to directly analyze the patient behaviors that comprise self-management. Specifically, we’ve gathered data with respect to: (a) self-monitoring; (b) data processing; (c) data evaluation; (d) decision-making; (e) action; and (f) self-efficacy. The proposed self-management program is based upon these our findings. Specific information that should be obtained each time a patient visits his or her primary health care provider should include:
a. Self-monitoring. The nurse should ask patients about how their condition is doing, if there have been any changes, and how they responded to the changes. Nurses may wish to use a disease diary, but only for limited times. The purpose of the use of self-monitoring would be to teach patients to be accurate observers of their own chronic condition (in some cases, careful self-monitoring may, in and of itself, produce behavioral change). Exactly how much data they gather on themselves varies according to the patient, but all patients can learn to detect basic changes in their condition.
b. Data processing and evaluation. Data gathered by patients is often entered into a diary or disease progression form. When faithfully gathered, the patient can observe how events change over time. Patients need to assess whatever changes they happen to see and how they use this information. People, often in imaginative and idiosyncratic manners, use different strategies in evaluating whatever information they collect. They go through trial-and-error tactics to find out what helps them best evaluate change; their strategies are central to the management of a chronic disorder. The role of the nurse is to learn of these strategies, particularly as they often deviate from the perceptions of health care providers.
c. Decision-making. The decision-making of patients is a fascinating subject: the rules of decision-making they use can be equal that of expert physicians in making the most appropriate decision and action to control condition (Creer, 1990; 2005). Decision-making, along with self-monitoring, is another area that can stand independently in self-management. In other words, by focusing on effective decision-making rules used by patients, one can often determine why some patients are so good at managing an exacerbation of a chronic condition.
d. Action. Information on whatever actions a patient takes with respect to his or her chronic condition, particularly during an exacerbation, should be discussed with the nurse. Health care providers can often learn about imaginative actions patients often take to control their disorder, particularly the exacerbations they experience. In addition, the nurse can provide suggestions to the patient about what actions he or she takes seems to be helpful. It is important that the nurse not be judgmental in listening to patients. They experience the chronic condition and they often know more about the reality of how it should be managed than anyone else.
e. Self-efficacy. How the patient reacts to the steps he or she has performed is of paramount interest. If what is done is successful, the patient is apt to do it again regardless of whether it makes any sense to health care personnel. It worked for the patient and that’s all that counts to that patient. The major issue in self-reaction, however, is to determine the self-efficacy, or confidence the patient has about management a chronic condition in given situations. If there is no self-efficacy, there will be no effective self-management. It’s that simple.
• Information on these topics can be obtained during each patient visit via a series of questions, not exceeding five, that are asked by nurses. In addition to gaining invaluable information, the questions should enhance patient commitment, clarify any questions either the patient or health care personnel have, increase the patient’s self-efficacy, and, overall, make the patient a stronger health partner. It should achieve the latter goal for the physician at well.
• One cannot count on the perfect nurse to administer the program in the office of a primary care physician; these nurses are the exception. However, if a nurse will only listen, ask prudent questions, and reinforce the patient, it is a win/win situation in increasing the health partnership. Nurses now have their own section in NIH--the National Institute of Nursing Research--and they are committed to providing quality health care to patients. Their commitment to behavioral research, particularly self-management research, is equal to that of any other section of NIH.
• Most nurses will initially require a manual to help guide them through the new arrangements they will have vis-a-vis patients. There are a number of manuals describing self-management processes for chronic diseases (e.g., Lorig et al., 2000). The skills needed for the self-management of any illness can be tailored both for given conditions and to fit the current and future needs of patients, particularly those needs generated by comorbid conditions.
• Brief courses for nurses and other health care providers are currently offered for teaching self-management skills to patients. As nurses are the most willing recipients of such training, it would be like preaching to the choir. The Patient Education Research Center at Stanford University offers periodic courses in using self-management with chronic diseases. These classes are taught via the Internet. The model used by Kate Lorig, the director of the Center, has proven efficacy and value.
• Self-management programs are often based solidly on previous research on self-management, including that conducted by use by my colleagues and I and the Stanford group. What the proposed program would accomplish is translating what we know to alter in a postive manner the most basic interactions primary care physicians and their staff have with patients. Only in this manner can the medical and behavioral knowledge and experience we have make a difference in chronic illness, including the run away costs of the conditions.

VIII. CONCLUSIONS

The review examined different aspects of the chaos that characterizes health care in the United States. It described, in stark reality, the prevalence of chronic illness and the skyrocketing costs incurred in attempting to control the conditions. Existing mechanisms for treating illness, including chronic conditions, were outlined. At the moment, nothing seems to be working that well, although there appears to be no significant momentum for changing the system. The paper mainly focused on the need for universal training in self-management for all patients, including those with a chronic illness. Self-management offers the only way that patients can assume greater responsibility for their health care and, in turn, provides the only feasible way to reduce the burden of health care costs. The review concluded with detailed suggestions on how self-management can be introduced into primary care. Most care for chronic illness is provided in primary care settings; if self-management training is going to be universal, it must be conducted in this setting. This modest proposal offers the best of all worlds: it incorporates a proven way of involving patients in their own care in a setting that is already in place. It also offers the only proven way of reducing the burden of chronic illness.

References

Anderson GF. Medicare and chronic conditions. N Engl J Med 2005; 353: 305-309.

Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Affairs, 2005;24:903-914.

Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003; 1:15-21.

Bodenheimer T, Lorig, K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469-2475.

Bodenheimer T, Wagner EH, Crumbach K. Improving primary care for patients with chronic illness. The Chronic Care Model, part 2. JAMA, 2002; 288:1909-1914.

Caplin DL, Creer TL. A self-management program for adult asthma. III. Maintenance and relapse of skills. J Asthma 2001;38: 343-56.

Cassell EJ. Doctoring: the nature of primary care medicine. New York: Oxford University Press, 1997.

Centers for Disease Control. CDC arthritis surveillance survey. Atlanta: Centers for Disease Control, 2002.

Centers for Disease Control. CDC asthma surveillance survey. Atlanta: Centers for Disease
Control, 2003.

Centers for Disease Control. The burden of chronic diseases and their risk factors. National and state perspectives. Washington DC: Department of Health and Human Services, 2004.

Creer TL. Self-management of a chronic physical disorder: childhood asthma. Athens OH: Department of Psychology, Ohio University, 1983.

Creer, T.L. Strategies for judgment and decision making in the management of childhood asthma. Ped Asthma, Allergy Immunol, 1990; 4: 253-264.

Creer TL. Self-management of chronic illness and disease management. In NA Cummings, WT O’Donohue, EV Naylor (Eds.), Psychological approaches to chronic disease management. Reno NV: Context press, pp. 149-183.

Creer TL, Backial M, Burns KL, Leung P, Marion RJ, Miklich DR, Morrill C, Taplin PS, &
Ullman S. Living with Asthma: Part I. Genesis and development of a self-management program for childhood asthma. J Asthma 1988; 25: 335-362.

Creer TL, Caplin DA, & Holroyd KA. A self-management program for adult asthma: part IV, Analysis of context and patient behaviors. J Asthma 2005;42:455-462.

Creer TL, Holroyd KA. Self-management of chronic conditions: The legacy of Sir William Osler. Chronic Illness, 2006;2:7-14.

Creer TL & Leung P. The development and evaluation of a self-management system for asthma. Vol. II. Manuscripts. Bethesda, Md.: National Institute of Allergy and Infectious Diseases, 1981.

Davis, K. (2005). President’s message. Transformational change: a ten-point strategy to achieve better health care for all. Presidents message, 2004 annual report, 2004, Commonwealth Fund, Publication no. 83.

Doty MM, Edwards JN, Holmgren AL. Seeing red: Americans driven into debt by medical bills. Results from a National Survey. Issue Brief, 2005; No. 837:1-12.

Druss RG. Another brand of medicine. Ann Intern Med 2004;141:962-963.

Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH. Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004; 13:299-305.

Fischer P. The emperor’s new clothes. J Fam Pract, 1993; 37: 543-544.

Fuchs VR, Emanuel EJ. Health care reform: why? What? When? Health Aff, 2005; 24:1399-1414.

Gabel J, Claxton G, Gil I, Pickreign J, Whitmore H, Holve E, Finder B, Hawkins S, Rowland D. Health benefits in 2004: four years of double-digit premium increases take their toll on coverage. Health Affairs, 2004;23:200-209.

Gabel J, Claxton G, Gil I, Pickreign J, Whitmore H, Finder B, Hawkins S, Rowland D. Health benefits in 2005: premium increases slow down, coverage continues to Erode. Health Affairs, 2005;24:1273-1280.

Geyman JP. Health care in America. Can our ailing system be healed? Boston: Butterworth-Heinemann, 2002.

Glasgow RE, Hiss RG, Anderson RM, Friedman NM, Hayward RA, Marrero DG, Taylor CB, & Vinicor F. Report of the health care delivery work group. Diabetes Care 2001; 24; 124-130.

Heffler S, Smith S, Keehan S, Borger C, Clemens MK, Truffer C. Trends: U.S. Health Spending Projections For 2004-2014. Health Affairs Web Exclusive. 2004;W4-79-W4-93.

Holman H. Chronic disease--the need for a new clinical education. JAMA 2004; 292: 1057-1059.

Holtz-Eakin D. An analysis of the literature on disease management programs. Congressional Budget Office, October 13, 2004 (downloaded from http://www.cbo.gov).

Infante FA, Proudfoot JG, Powell Davies G, Bubner TK, Holton CH, Beilby JJ, Harris MF.
How people with chronic illnesses view their care in general practice: a qualitative study. Med J Aust 2004; 181:70-73.

Institute for the Future. Health and health care 2010: The forecast, the challenges. San Francisco: Jossey-Bass, 2000.

Jemal A, Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, Feuer EJ, Thun MJ. Cancer statistics, 2005. CA Cancer J Clin, 2005;55:10-30.

Klein K, Glied S, Ferry D. Entrances and exits: health insurance churning, 1998-2000.
Issue Brief, 2005; No. 855:1-12.

Kleinke JD. Oxymorons. The myth of a U.S. health care system. San Francisco: Jossey-Bass, 2001.

Kralik D, Koch T, Price K, Howard N. Chronic illness self-management: taking action to create order. J Clin Nurs 2004; 13:259-267.

Levit K, Smith C, Cowan C, Sensenig A, Catlin A; Health Accounts Team. Health spending rebound continues in 2002. Health Affairs, 2004;23:147-159.

Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a healthy life with chronic conditions: self-management of heart disease, diabetes, asthma, bronchitis, emphysema and others. Palto Alto, CA: Bull Publishing, 2000.

Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW Jr, Bandura A, Gonzalez VM, Laurent DD, Holman HR. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care 2001; 39:1217-1223.

Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Eff Clin Pract 2001; 4:256-262.

Lucas DO, Zimmer LO, Paul JE, Jones D, Slatko G, Liao W, Lashley J. Two-year results from the asthma self-management program: long-term impact on health care services, costs, functional status, and productivity. J Asthma 2001; 38:321-330.

Oberlander J. The US health care system: On a road to nowhere? CMAJ 2002; 167: 163-168.

Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Sys Rev 2001; 1: CD001481.

Rothman AA, Wagner EH. Chronic illness management: what is the role of primary care. Ann Intern Med 2003; 138: 256-261.

Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh, J, Davis K. Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Health Aff 2005; DOI 10.1377//hthaff.W5.509.

Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity:
implications for the importance of primary care in “case” management. Ann Fam Med, 2003; 1:8-14.

U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States: 2003. Washington: U.S. Government Printing Office, 2004.

Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med 1997; 127: 1097-1097.

Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness.
Millbank Q, 1996; 74: 511-544.

World Health Organization. The World Health Report, 1997: Conquering suffering, enriching humanity. Geneva: World Health Organization, 1997.

Tom Creer
June 8, 2007