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Abstract
An estimated 99 million Americans live with a chronic illness. Meeting the needs of
this population is one of the major challenges facing the U.S. health care system
today and in the future. Dozens of studies, surveys, and audits have revealed that
sizable proportions of chronically ill patients have not received effective therapy
and do not have optimal disease control. The consistent findings of generally substandard
care for many chronic conditions have spurred proposals that care be shifted to specialists
or disease management programs. Published evidence to date does not indicate any clear
superiority of these alternatives to primary care. The defining features of primary
care (that is, continuity, coordination, and comprehensiveness) are well suited to
care of chronic illness. A rapidly growing body of health services research points
to the design of the care system, not the specialty of the physician, as the primary
determinant of chronic care quality. The future of primary care in the United States
may depend on its ability to successfully redesign care systems that can meet the
needs of a growing population of chronically ill patients.