No Time to Go Backwards.

Current market forces are driving healthcare executives to make short-term survival decisions that unintentionally uncouple important services for the chronically ill.

Hospitals, physician groups, skilled nursing facilities and home health agencies are all reeling from a plethora of new Medicare and Medicaid requirements and marketplace conditions. Providers are spinning off "soft money" programs and re-establishing old-line hospital nursing home operations as their core business. Specialized programs for the chronically ill, including PACE, Social HMOs, dually eligible demonstrations, EverCare and private sector companies focused on managing care for the frail elderly, are reassessing their ability to survive an onslaught of regulatory and financial pressures. Providers everywhere are returning to what they did well in the past as a way to succeed over the long term.

There is an old saying, "If you do not know which shore you are heading toward, any wind can get you there." As health care executives work their way through the current sea of change, it is important to remember that problems of chronic illness continue to be multidimensional, interdependent, interpersonal and ongoing. Our ability to contain costs and ensure quality over the long term are still linked to the ability of all primary, acute and long-term care providers to see themselves as part of the same care team.

It is clear that healthcare executives must respond to the pressures of the moment in order to survive. But we cannot blind ourselves to the importance of building systems of care that embrace collective action with a long-range view. We cannot abandon a population whose costs already account for the vast majority of all health and long-term care costs in America. We cannot step away from a commitment to be leaders in addressing what is perhaps the single most important healthcare problem of the 2lst century.

To survive to day and prepare for tomorrow, healthcare executives must move beyond the shoring up of old, mainstream institutions, and instead find ways to embrace more person-centered, home-based, system-oriented approaches to care. They must find ways to see public health, primary care, acute care and long-term care as integrally linked. Utilization management must extend beyond the silos of hospitals, nursing homes, home health agencies and clinic operations to questions about what combination of care is most cost-effective. Along these lines:

* Disease management guidelines must provide whatever combination of care that will be most costeffective for preventing, delaying or minimizing disability progression and for ensuring continuity of care across settings.

* New administrative, financing and information systems must enable providers to manage chronic conditions as they evolve over time and require the involvement of multiple care providers.

* We must embrace policies that create incentives for providers to target high-cost cases, to identify risks for disease and disability progression, to minimize use of high-cost services and to establish new and innovative interventions. And this should occur regardless of what piece of the care continuum might benefit directly.

We have made great strides in medical and healthcare technology. We are entering the new millennium with more potential for eradicating disease and disability than ever before. Yet it is important to learn how to live with chronic disease and disability until we know how to prevent it. Current healthcare methods defy logic of quality care for the chronically ill.

Integrated health systems, long-term care alliances, specialized clinics, chronic care management companies and public officials focused on the integration of Medicare and Medicaid must join forces to develop tools and technology that restrain the escalation of costs through improved care interventions. They must develop a sense of how each part of healthcare contributes to the whole.

We are polishing the brightwork while the winds of change drive us to unwanted shores. We cannot abandon our true destination. We must identify what is crucial to stay the course, and do it now.

Richard Bringewatt is president and CEO, National Chronic Care Consortium, Bloomington, Minnesota.