1
Introduction

Many individuals with chronic conditions are concerned about the trend toward the creation of managed care systems. On the one hand, managed care systems seem ideal for integrating the financing and delivery of primary, acute, and chronic care of the types that such patients require; on the other hand, a major stimulus to the growth of managed care has been the hope that they will halt the spiraling costs of health care. Individuals with serious chronic conditions are likely to be frequent users of medical services (often complex sets of services requiring specialist attention) and to need assistance with daily living tasks. Consequently, a concern is growing that persons with serious chronic disorders will be excluded from, be underserved by, or receive inappropriate care from the kinds of integrated delivery networks now emerging.

Little information exists on the number of adults under age 65 with significant chronic conditions who are enrolled in managed care plans. Even less is known about differences in outcomes of care of individuals with chronic conditions across the array of managed care models. The present study grew out of the desire of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) to convene significant stakeholders and researchers to determine what information can be gleaned from existing data and delineate the key research questions needed to address concerns regarding the effect of the changing health care system on the quality of care for individuals with chronic conditions, particularly chronic rheumatic diseases. Specifically, the Institute of Medicine (IOM) was charged with planning and conducting a workshop focused on the following questions:

  1. Does the model of managed care or integrated delivery system (e.g.,


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--> 1 Introduction Many individuals with chronic conditions are concerned about the trend toward the creation of managed care systems. On the one hand, managed care systems seem ideal for integrating the financing and delivery of primary, acute, and chronic care of the types that such patients require; on the other hand, a major stimulus to the growth of managed care has been the hope that they will halt the spiraling costs of health care. Individuals with serious chronic conditions are likely to be frequent users of medical services (often complex sets of services requiring specialist attention) and to need assistance with daily living tasks. Consequently, a concern is growing that persons with serious chronic disorders will be excluded from, be underserved by, or receive inappropriate care from the kinds of integrated delivery networks now emerging. Little information exists on the number of adults under age 65 with significant chronic conditions who are enrolled in managed care plans. Even less is known about differences in outcomes of care of individuals with chronic conditions across the array of managed care models. The present study grew out of the desire of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) to convene significant stakeholders and researchers to determine what information can be gleaned from existing data and delineate the key research questions needed to address concerns regarding the effect of the changing health care system on the quality of care for individuals with chronic conditions, particularly chronic rheumatic diseases. Specifically, the Institute of Medicine (IOM) was charged with planning and conducting a workshop focused on the following questions: Does the model of managed care or integrated delivery system (e.g.,

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--> fully capitated managed care, gatekeeper-only model of managed care, discounted fee for service) influence (a) the types of interventions provided to patients with chronic conditions and (b) the clinical and health status outcomes of those interventions? If so, are these effects quantitatively and clinically significant, as compared to the effects that other variables (such as income, education, or ethnicity) have on patient outcomes? If the mode of health care delivery system appears to be related to patient care and outcomes, can specific organizational, financial, or other variables be identified to account for the relationships? If not, what research agenda should be pursued to provide critical information about the relationship between types of health care systems and the processes and outcomes of care delivered to populations with serious chronic conditions? NIAMS further suggested, in the interest of coherence, focusing the workshop on two autoimmune diseases with characteristics that would make them, as a set, case studies representative of other rheumatic diseases and chronic diseases in general. Systemic lupus erythematosus (SLE) is an intermittent, relapsing illness with effects that involve multiple organ systems. The main organs affected are joints, skin, kidney, brain, heart, and lungs. There is a relatively high probability of death at a young age, but the illness itself has the characteristics of an intermittent illness with peaks and valleys of severity and remission. In contrast, rheumatoid arthritis (RA) is an ailment that can range from very minor symptoms over a long time to an extremely crippling disorder with physical deformity of the joints—that is, it is a model of chronic, progressive, and severely disabling disease. Although persons with RA also have a reduced life expectancy, RA does not generally pose the same threat to life as SLE does. A considerable amount of information is already available about these two diseases; they represent quite different clinical, epidemiological, and social problems; and both diseases are significant contributors to morbidity and health care costs in the United States. Changing Health Care Systems In the early decades of this century the purchase and delivery of health care in the United States resembled typical transactions in other fields: patients directly purchased all or nearly all services from a general practitioner in solo practice. Rapidly accelerating growth in new medical knowledge and technology improved medical care, but increased both the number of specialists and the costs of treatment. Health insurance, most often subsidized by employers, assumed an increasingly important role after World War II. It

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--> helped consumers predict and control out-of-pocket expenses but, in the opinion of many, contributed to unsustainable rates of increase in medical costs by reducing patient concerns about price. The public policy and the payer response to these costs have been ''managed care.'' Managed care has many meanings. The most fundamental feature of managed health care is the "management" of physician practice. This occurs in the form of the selection and retention of physicians into eligible provider networks, utilization and practice pattern profiling and feedback, limits on provider reimbursement, financial risk sharing or other financial incentives to reduce costs, and most recently, practice guidelines specifying appropriate care for specific diagnoses. Varying combinations of these procedures are used within any one managed care plan or organization. As characterized by Miller and Luft1 managed care plans include health maintenance organizations or HMOs, preferred provider organizations (PPOs), and point-of-service (POS) plans. HMOs themselves come in a variety of forms. Staff model HMOs (e.g., Group Health Cooperative) are characterized by directly employing physicians. Another type of HMO is the prepaid group practice (or group model HMO) in which an administrative entity (e.g., Kaiser Foundation Health Plan) has an exclusive relationship with one or more large medical groups (e.g., the Permanente Medical Group). This contrasts with a network HMO (e.g., Pacificare Health Systems) in which the medical group relationship is not exclusive. Finally, there is a mixed model HMO (e.g., Prudential Health Care Plans Inc.) in which the administrative intermediary may contract exclusively with medical groups and nonexclusively with solo practice physicians in the same area. Preferred provider organization refers to the combination of financial intermediary organization and the network of providers with which it contracts to provide care. Providers in these organizations offer care to PPO enrollees on a fee-for-service (FFS) basis, generally at a discounted unit price from the community's "usual, customary, and a reasonable" price. Often there may be a preset fee schedule. PPO enrollees come from employer groups, unions, and other groups with which the PPO has negotiated the opportunity to recruit such members. Providers (e.g., solo and group practice physicians, hospitals, mental health and other providers) participating in a PPO usually have nonexclusive relationships (i.e., they may participate in more than one PPO and/or see patients independently). Providers participate in PPOs to gain ready access to patients. The absence of risk sharing by providers in a PPO places the incentives for utilization control on the PPO rather than the provider. PPOs have historically covered services from providers outside the plan's network 1   Miller, R, and H Luft (1994). Managed care plans: characteristics, growth, and premium performance. Annual Review of Public Health, 15: 437–459.

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--> at a lower rate and with higher copayments by the patient. Point-of-service plans are variations on the provider "lock-in" provisions of both HMO and PPO coverage. The distinguishing characteristic of a POS plan is that enrollees can be covered for services obtained outside of the HMO or PPO network providers. When this is done, service copayments and deductibles usually are higher than they would be from a network provider. This type of coverage within an HMO is also called an "open-ended HMO plan." Both HMOs and PPOs are increasingly offering a point-of-service option for their enrollees. This typology emphasizes the variations in the relationship between health care providers and the managed care organization. An alternative typology might instead emphasize the manner in which the consumer (the patient) pays for health care. Many of the earliest managed care plans were staff model HMOs that paid their providers a fixed salary and in turn charged their members (patients) a fixed annual fee independent of services required or received. Later variations, which did not actually employ providers, extended their members a similar fixed annual fee plan by paying their contracted providers a fixed amount per member (capitation). As noted above, many of the PPOs and POS plans that have flourished most recently have returned to an FFS payment system and have cut costs instead by using their large membership to negotiate reduced fees with participating providers. Managed care plans began to become more widespread during the 1980s as employers reacted to high rates of increase for indemnity health care insurance premiums. By 1993, all types of HMO plans covered 26 percent of the employees of mid-and large-size employers. Other forms of managed care (e.g., PPO and POS) had enrolled 36 percent of those insured, while those covered by indemnity insurance had declined to 42 percent.2 The movement from indemnity toward managed care coverage has varied greatly by region of the country and local market area, but the trend toward capitation as the dominant payment method seems established. Although no consensus has developed concerning the ideal managed care strategy, some now estimate that indemnity products will represent only about 10 percent of the insurance market by the turn of the century.3 As a recent IOM report noted,4 medical practices and plans across the country are devising a variety of ways to provide affordable health care within the limits of this country's preferences 2   McMillan, A (1993). Trends in Medicare health maintenance organization enrollment: 1986–1993. Health Care Financing Review, 15:135–46. 3   Armstead, R, P Elstein, and J Gorman (1995). Toward a 21st century quality-measurement system for managed-care organizations. Health Care Financing Review, 16: 25–37. 4   Institute of Medicine (1994). Defining Primary Care: An Interim Report. Washington, DC: National Academy Press.

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--> for high technology, a wide choice of providers, and particular methods of financing and organization. Chronic Disease Today's health care system has emerged from an era during which acute and dramatic illness resulted in one of two possible outcomes: either the patient died or the patient recovered fully within a relatively short, defined period. Delivery mechanisms were designed to respond effectively to such acute episodes of illness. This system is predicated on the assumptions that disease onset is abrupt, often caused by a single agent, limited in duration, and subject to a relatively accurate diagnosis and prognosis. The aim of intervention is return to normal health (cure). The professional often relies heavily on technology and assumes the role of a knowledgeable expert who controls a traditional doctor-patient relationship. The patient, in turn, endures the disease process as a passive recipient of medical intervention struggling with surprise, ignorance, confusion, and fear. Ironically, the success of the traditional system in reducing mortality, along with improved public health programs, better nutrition, and the aging of those born in the post-World War II "baby boom" has created a vastly different patient population from the one faced by physicians in the first half of this century. Life expectancy in Europe and the United States has risen from less than 50 years at the end of the last century to more than 75 years in the 1990s, but chronic diseases now account for 80 percent of all deaths and 80 percent of all morbidity, and the rate of increase in chronic disease continues to surpass the growth of acute illness. Chronic disease demands a markedly different paradigm. By its nature, chronic disease is complex and continuing, and it must be understood as illness that penetrates and compromises, deeply and widely, all aspects of a patient's life. The aim of therapy is most often management of these impacts rather than cure; illness must be understood as an undulating, longitudinal process; maintenance of function and pain reduction may be as important or more important to the patient than modification of disease activity per se. Therapeutic interventions involve weighing the tolerability of the current level of illness against the risk of a proposed new therapy. Psychological responses and social support can play a significant role in coping with chronic illness, so the patient with a chronic disease becomes a uniquely involved participant in the system of care, and the system cannot hope to divest itself of this patient at the end of a single event of ill health.

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--> Rheumatic Disease More than 100 discrete disorders, with a wide variety of clinical manifestations, fall under the classification of rheumatic disease, but arthritis in its many forms is the most common disease evaluated in ambulatory care settings, accounting for an estimated 1.2 million physician visits annually.5 It is more prevalent and limits activity more frequently than heart disease, cancer, or diabetes.6 In fact, arthritis is the most prevalent cause of chronic physical disability and a leading cause of work disability and activity limitation in the United States.7 Rheumatoid arthritis, one of several types of arthritis, is an autoimmune disease that afflicts 1–3 percent of Americans. It is an inflammatory disorder affecting primarily joints, where it causes pain, swelling, and stiffness. The disease, which is two to three times more common in women than in men, usually strikes between the ages of 30 and 40. Ten to twenty percent of victims have an acute onset over a period of days, but symptoms are usually intermittent at first, with more problems emerging over time; clinical illness is greatest among those aged 40–60. Even with appropriate drug therapy, up to 7 percent of patients are disabled to some extent 5 years after disease onset, and 50 percent are too disabled to work 10 years after disease onset. Treatment includes physical therapy to maintain mobility, drugs to slow or halt the disease and/or ameliorate its effects, and occasionally, orthopedic surgery to repair damage or replace nonfunctional or painful joints. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have supplanted aspirin as the most common initial drug treatment, but most RA patients eventually receive disease-modifying arthritis drugs (DMARDs). These include methotrexate, gold compounds, penicillamine, and antimalarial drugs such as hydroxychloroquine, which are thought to go beyond symptom relief. Up to 20 percent of patients may experience complete remission, and roughly half of the remaining patients will experience stabilization of the disease while under treatment. DMARDs are not always effective, however, and often prove too toxic for chronic use. Unfortunately, RA almost always recurs when DMARDs are discontinued. 5   Yelin, EH, and WR Felts (1990). A summary of the impact of musculoskeletal conditions in the United States. Arthritis and Rheumatism, 33: 750–755. 6   Lawrence, RC, MC Hochberg, JL Kelsey, FC McDuffie, TA Medsger, WR Felts and LE Shulman (1989). Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. Journal of Rheumatology, 16: 427–441. 7   Reynolds, MD (1978). Prevalence of rheumatic diseases as causes of disability and complaints by ambulatory patients. Arthritis and Rheumatism, 21: 377–382. Yelin, EH, and WR Felts (1990). op. cit. Centers for Disease Control and Prevention (1994). Arthritis prevalence and activity limitations—United States, 1990. Morbidity and Mortality Weekly Report, 43: 433–438.

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--> Systemic lupus erythematosus is also an autoimmune disease characterized by chronic inflammation. Although joints are often affected, SLE is far more general in its effects. Skin rashes and lesions, often on the face and highly sensitive to sunlight, are characteristic, but inflammation of the tissues surrounding the heart may occur in up to 30 percent of cases; half of all cases may involve the kidneys, and 40–50 percent of cases may affect the lungs at some point in the course of the disease. Involvement of the central nervous system, particularly with cognitive impairment, is common. Involvement of the gastrointestinal tract is less frequent but not uncommon. Overall prevalence of SLE is 15 to 51 cases per 100,000. Ninety percent of the cases are women, and black women have three times the incidence and mortality of white women. As many as 1 in 250 black women will get SLE. Onset of the disease is usually between the ages of 15 and 40; onset during childhood is associated with a more severe course, and onset after age 50 with a milder course. The actual course of SLE varies widely depending on the pattern of organ system involvement but, in general, is one of relatively asymptomatic intervals punctuated by exacerbations of varying severity. Individuals with severe kidney disease, hypertension, anemia, hypoalbuminemia, or hypercomplementemia have mortality rates that approach 50 percent over 10 years, but some individuals have mild disease that produces disability but does not shorten lifespan. As in the case of RA, medication usually begins with NSAIDs, often in combination with corticosteroids. Antimalarial drugs are commonly used for cutaneous, musculoskeletal, and mild systemic symptoms, although the mechanism of action is unknown. Immunosuppressive agents are reserved for patients for whom conventional therapy has failed. The toxic effects of all of these drugs must be monitored closely, and relapse is frequent with discontinuation. Practices and Achievements of Managed Care Systems Published studies directly comparing the treatments received and/or outcomes achieved by persons with RA or SLE under various models of medical care organization and financing are practically nonexistent. Two studies comparing RA patients in FFS arrangements with RA patients in prepaid group practice HMOs were published by Yelin and colleagues in the mid-1980s.8 They are not discussed in detail here, since Yelin provides an 8   Yelin, EH, CJ Henke, JS Kramer, MC Nevitt, M Sheam, WV Epstein (1985). A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee for service practices. New England Journal of Medicine, 312: 962–967. Yelin, EH, M Sheam, and WV Epstein

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--> update on this longitudinal study in a subsequent section of this volume. In a sentence, Yelin and his colleagues reported that RA patients in prepaid systems received similar kinds and amounts of health care and achieved similar outcomes as their FFS counterparts. Similar findings were reported by Ward, et al.9 at the 1995 meeting of the American College of Rheumatology. The remainder of this section briefly reviews some of the many comparisons of FFS health care with HMOs, most often of the prepaid staff or group practice type, that have not specifically focused on RA or SLE, or even chronic disease. Hospital Use One of the principal ways HMOs have reduced their costs relative to FFS systems is by controlling hospital admissions and lengths of stay. Prior to the advent of widespread managed care systems and diagnosis-related hospital reimbursement,10 HMOs serving the non-Medicare population showed reductions of 10–40 percent in hospital days over FFS indemnity reimbursed care.11 During the 1980s and early 1990s, studies have been less consistent in this finding. The Medical Outcomes Study found that HMO hospital utilization was 26–37 percent below FFS.12 Other studies, including the Medicare risk contract evaluation, have shown small and statistically insignificant differences in admissions.13 This latter finding likely reflects the     (1986). Health outcomes for a chronic disease in prepaid group practice and fee for service settings. Medical Care, 24: 236–247. 9   Ward, MM, JP Leigh, and D Lubeck (1995). Long-term health outcomes of patients with rheumatoid arthritis treated in managed care and fee-for-service practice settings (abstract 437) Arthritis and Rheumatism, 38 (suppt): S225 10   Beginning in 1985, the Medicare program began a prospective payment system for hospitals based on a patient's diagnosis. This program reimburses the hospital a set amount for each of a set of diagnoses, regardless of the length of stay and thus provides an incentive for hospitals to reduce lengths of stay. The RAND Corporation and others have shown that unnecessarily lengthy stays diminished and the proportion of patients judged to be receiving "poor" or "very poor" care decreased from 25 to 12 percent. On the other hand, there was approximately a doubling in the proportion of patients (i.e., 7 percent versus 4 percent) discharged too soon or in an unstable condition. [Kosecoff, J, K Kahn, W Rogers, et al. (1990). Prospective payment system and impairment at discharge: the quicker-and-sicker story revisited. Journal of the American Medical Association, 264: 1980–1983.] 11   Luft, H (1987). Health Maintenance Organizations: Dimensions of Performance. New Brunswick, CT: Transition Books. 12   Greenfield, S, E Nelson, and M Zubkoff (1992). Variations in resource utilization among medical specialties and systems of care: Results from the Medical Outcomes Study. Journal of the American Medical Association, 267: 1624–1630. 13   Miller, M, and H Luft, op. cit.

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--> decline in FFS hospital admissions per Medicare beneficiary by 25 percent between 1985 and 1989. These differences extend to hospital days per enrollee. Among Medicare risk plans, hospital days per enrollee were 6–9 percent fewer than the fee for service comparison group, although group and staff model plans had longer lengths of stay than Independent Providers Association (IPA)-network model plans.14 In an analysis of the 12 (out of 30) most rigorously conducted evaluations of the impact of Medicaid managed care programs, Hurley et al.15 found that four MCOs decreased in patient use, one increased use and the other five had no impact. Other studies of enrolling Medicaid eligibles are similar and do not uniformly find reductions in either admissions or lengths of stay.16 Physician Use The relative reduction in inpatient services within HMOs and managed care systems carries an implied assumption that physician or other services expand to accommodate a shift in care to an outpatient setting. There is no consistent empirical support for this. Of 14 studies reviewed by Miller and Luft,17 7 showed lower physician use (3 were statistically significant) and 7 higher use (5 were statistically significant). Complicating such comparisons are the parallel decline in inpatient days within the FFS sector and differences among the various managed care models. For example, in the Medicare risk contract evaluation by Brown and Hill, staff and group models had substantially higher physician visit rates (19–25 percent more visits than FFS) than network-IPA plans (3 percent fewer visits than FFS).18 Though it often has been hypothesized that managed care for Medicaid would mean greater use of physician services, this has not been shown to be the case. In the evaluation of 12 programs by Hurley and colleagues, three programs were found to experience an increase in physician visits, 5 14   Brown, R, and J Hill (1993). Does Model Type Play a Role in the Extent of HMO Effectiveness in Controlling the Utilization of Services? Princeton, NJ: Mathematica Policy Research Inc. 15   Hurley, R, D Freund and J Paul (1993). Managed Care in Medicaid, Lessons for Policy and Program Design. Ann Arbor, Michigan: Health Administration Press. 16   Miller, M, and M Gengler (1993). Medicaid case management: Kentucky's patient access and care program. Health Care Financing Review, 15: 55–69. Buchanan, J, A Leibowitz, and J Keesey (1996). Medicaid health maintenance organizations: Can they reduce spending? Medical Care, 34: 249–263. Leibowitz, A, J Buchanan, and J Mann (1992). A randomized trial to evaluate the effectiveness of a Medicaid M/HMO. Journal of Health Economics, 11: 235–257. 17   Op. cit. 18   Op. cit.

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--> experienced a decrease, and the remainder had no change.19 A study of the first Medicaid Competition Demonstration found an overall decline in primary care physician use and a decrease in the total number of physicians seen.20 Such "concentration of care" in the hands of fewer doctors, however, is what one expects from medical plans that require enrollment with a primary care gatekeeper. Rates of referrals to specialists in Medicaid managed care programs appear to be uniformly lower than in fee-for-service Medicaid. Studies of the Medicaid Competition Demonstrations21 found that the probability of seeing a specialist at least once during the year declined by at least 30 percent in all sites studied but one. Tests and Procedures Another presumed means of HMO savings is to use fewer services or to substitute less costly services when possible. Access to appropriate tests and procedures is both an important example of such cost controls and a presumed indicator of the quality of care within health plans. There is some evidence that HMOs are economical in the use of tests and procedures, while still being attentive to prevention and health promotion. Findings from 14 studies reviewed by Miller and Luft22 showed either better or equivalent access to tests and procedures. This was interpreted as indicative of quality of care. These studies generally showed that enrollees, whether Medicare beneficiaries or from group enrollment, were likely to receive the same or more frequent levels of routine and preventive care (such as cancer and hypertension screening tests; breast, pelvic, rectal, and general physical examinations) and to receive care similar to that received by nonenrollees for a variety of specific conditions. For example, analyses from the Medicare Competition Demonstration found that enrollees generally received tests and treatment comparable to nonenrollees for congestive heart failure, colorectal cancer, diabetes, and hypertension.23 Similar findings were also found in the 19   Op cit. 20   Freund, DA, L Rossiter, et al. (1989). Evaluation of the Medicaid Competition Demonstration. Health Care Financing Review, 11: 81–97. 21   Ibid. Freund, D, and E Lewit (1993). Managed care for children and pregnant women: Promises and pitfalls. The Future of Children, 3: 92–122. 22   Op. cit. 23   Preston, J, and S Retchin (1991). The management of geriatric hypertension in health maintenance organizations. Journal of the American Geriatric Society, 39: 683–690. Retchin, S, and B Brown (1990). Quality of ambulatory care in Medicare health maintenance organizations. American Journal of Public Health, 80: 411–415. Retchin, S, and B Brown (1990). Management

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--> treatment of stroke among Medicare risk contract plans,24 rates of cancer screening with the National Health Interview Survey,25 and an analysis of myocardial infarction within the HMO Quality of Care Consortium. This latter study found greater compliance with process of care criteria among HMO physicians and nurses compared to a sample of fee-for-service providers. Only in the area of diagnostic testing (e.g., electrocardiograms and chest radiographs) did FFS compliance with guidelines exceed that of HMOs.26 A review of the published literature on Medicaid and managed care27 reported recent studies showing a higher percentage of 3-year-olds with up-to-date immunizations for managed care28 and a higher percentage of breast examinations and Pap smears for women in Medicaid managed care programs29 but it concluded that, overall, the use of preventive care services does not appear to either improve or decline under most Medicaid managed care arrangements. One demonstration evaluation approached the quality of care issue from a different perspective: the comparison of changes in health status, life expectancy, and active life expectancy among prepaid plan members and those with FFS indemnity coverage. These results suggest generally comparable performance between the prepaid and indemnity systems among most health status groups. Prepaid health plan performance slightly trailed that of FFS in the case of female members, but performance of the two types of coverage was     of colorectal cancer in Medicare health maintenance organizations. Journal of General Internal Medicine, 5: 110–114. Retchin, S, and B Brown (1991). Elderly patients with congestive heart failure under prepaid care. American Journal of Medicine, 90: 236–242. Retchin, S, and J Preston (1991). The effects of cost containment on the care of elderly diabetics. Archives of Internal Medicine, 151: 2244–2248. 24   Retchin, S, D Clement, and B Brown (1994). Care of patients hospitalized with strokes under the Medicare risk program. Pp. 167–194, in H Luft, Ed., HMOs and the Elderly. Ann Arbor, MI: Health Administration Press. 25   Bernstein, A, G Thompson, and L Harlan (1991). Differences in rates of cancer screening by usual source of medical care: Data from the 1987 National Health Interview Survey. Medical Care, 29: 196–209. 26   Carlisle, D, A Siu, E Keeler, K Kahn, L Rubenstein, and R Brook (1994). Do HMOs provide better care for older patients with acute myocardial infarction? Pp. 195–214, in H. Luft, Ed., HMOs and the Elderly. Ann Arbor, MI: Health Administration Press. 27   Rowland, D, S Rosenbaum, L Simon, and E Chait (1995). A Report of the Kaiser Commission on the Future of Medicaid. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 28   Balaban, D, N McCall, and EJ Bauer (1994). Quality of Medicaid Managed Care: An Evaluation of the Arizona Health Care Cost Containment System (AHCCCS). San Francisco: Laguna Research Associates. 29   Carey, T, K Weis, and C Homer (1990). Prepaid versus traditional Medicaid plans: Effects on preventive health care. Journal of Clinical Epidemiology, 43: 1213–1220.

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--> comparable among males.30 Home Health and Skilled Nursing Care Reductions in hospital admissions and days within managed care or other systems might be expected to increase nursing home and home health care use. However, Medicare patients in managed care, after adjustment for case mix, tend to use about 15 percent fewer days of skilled nursing home care, 21 percent fewer nurse or therapist visits, and 28 percent fewer home health aid visits.31 These results do not directly connect the use of such services to post-hospital care; so it is possible that some reduction in hospital care is balanced by increased nursing home and home health care, but that this increase is offset by reductions in admissions to these services for other cases. Another study specifically examining the effects of post-hospital care for Medicare patients found that membership in an HMO had no significant effect on the likelihood of receiving various types of post-hospital care.32 Results from both of these studies should be interpreted in the context that managed care plans are financially at risk for nursing home and home health care services as well as hospital stays. Within the FFS sector, hospitals are at risk for days of care and thus have a greater incentive to shift patient care (and its associated financial risk) to other settings and providers. Outcomes of home health care have been examined in terms of improvement and stabilization in functional status, mortality, discharge to independent living, and hospital utilization. The most extensive of these studies looked at rehabilitation and cardiac patients and their home health service utilization. Fee-for-service patients received about one-third more total home health visits and at least twice the number of home health aide visits and social service visits. There were, however, no significant differences in the number of skilled nursing, physical therapy, or occupational therapy visits for these conditions. After adjustment for case mix, Medicare fee-for-service patients had better outcomes, relative to those in HMOs, on measures of 30   Manton, K, R Newcomer, G Lowrimore, J Vertrees, and C Harrington (1993). Social/health maintenance organization and fee for service health outcomes over time. Health Care Financing Review, 15: 173–202. 31   Brown, R, and J Hill (1994). The effects of Medicare risk HMOs on Medicare costs and service utilization. Pp. 13–49, in H Lull Ed., HMOs and the Elderly. Ann Arbor, MI: Health Administration Press. 32   Kane, RE, M Finch, L Blewett, Q Chen, R Burns, and M Moskowitz (1996). Use of post-hospital care by Medicare patients. Journal of the American Geriatric Society, 44: 242–250.

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--> functionality.33 Among those with mild or moderate levels of impairment on ''admission'' to home health care, between 6 and 16 percent more FFS patients improved status than did their HMO counterparts over 12 weeks. There were no differences among those beginning with severe levels of disability. Importantly, however, there were no differences in the proportion discharged to independent living within 12 weeks or in hospitalization within 12 weeks of the start of care. Social/Health Maintenance Organizations The first generation of this Medicare demonstration, known as the S/HMO, was implemented in 1985 with the objective of adding a package of chronic care benefits to the acute services and operational structure of the Medicare HMO model. These chronic care benefits included unskilled nursing home stays (usually a maximum of 30 days) and personal care, homemaker, and case management services. S/HMOs also offered expanded care benefits to all members, such as prescription drugs, eyeglasses, transportation, and preventive dental care. The liability of the plan for chronic care of any individual member was initially limited to $6,000–$12,000 per year depending on the plan, and did not extend to long-term care. The lessons learned in the first generation S/HMO program were that (1) merely placing a case management program into a health plan, even if charged with coordinating access to chronic care benefits, did not change the plan's usual approach to primary care or hospital care: (2) in part because of the absence of such structural changes, the plans realized no real savings in hospital and other medical costs from the provision of the added community care benefits; (3) limiting the target population to patients sufficiently impaired to qualify for nursing home placement may also have limited potential cost savings.34 Overall, S/HMOs would have to be judged a promising approach which has yet to be properly tested. A second generation S/HMO demonstration begins in late 1996, retaining the chronic care benefit package implemented in the first generation plans but adding several refinements, including a reimbursement formula directly tied to health care risk factors. 33   Shaughnessy, P, R Schlenker, and D Hittle (1994). Home health care outcomes under capitated and fee-for-service payment. Health Care Financing Review, 16: 187–221. 34   Harrington, C, M Lynch, and R Newcomer (1993). Medical services in social health maintenance organizations. The Gerontologist, 33: 790–800.

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--> Work Force Issues A near-universal target of cost saving measures proposed by health policy experts and implemented by health care plans of all varieties is specialty and subspecialty care. Although hard data are scarce, seldom involve measured outcomes, and most often address only one or two subspecialties, it is widely believed that specialist and subspecialist care is too expensive, less controllable, and sometimes unnecessary. The United States does in fact have a disproportionately high percentage of specialists compared to the rest of the world,35 and Wennberg and his colleagues36 reported that in 1989, successful HMOs were employing specialist and subspecialist physicians at per capita rates far lower than their prevalence in the United States would suggest. Managed care systems of all varieties now rely heavily on "primary care physicians" as gatekeepers, that is, a mandatory starting place for all patient-plan interactions and one that takes the decision to utilize a specialist out of the hands of the patient. Like the term managed care itself, primary care means many things to many people. Some understand primary in its sense of first in time or order, which leads to a narrow concept of primary care as simply first contact or entry point and connotes only a triage function. Others, including this committee, understand primary in its sense of chief, main, or principal, which leads to the definition of primary care recently promulgated by another IOM committee: Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.37 This definition, involved as it may be, does not specify the medical training required by physicians delivering primary care other than to require that they be able to address a large majority of their patients' health care needs. Context makes it clear that the authors are ruling out mere triage to subspecialists, although they recognize that part of managing a patient's problem may well require involving other practitioners. Nevertheless, the 35   Barondess, JA (1993). The future of generalism. Annals of Internal Medicine, 119: 153–160. 36   Wennberg, JE, DC Goodman, RF Nease, and RB Keller (1993). Finding equilibrium in U.S. physician supply. Health Affairs (Millwood), 12: 89–103. 37   Institute of Medicine (1996). Primary Care: America's Health in a New Era. Washington, DC: National Academy Press.

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--> question of who should deliver primary care remains a topic of lively debate. Rheumatologists, for example, argue that they should be the primary care providers for persons with rheumatic diseases pointing to data suggesting that RA patients do better with regular care by a rheumatologist.38 Proponents of a less specialized primary care physician, on the other hand, would argue that persons with rheumatic disease remain subject to all the other health problems with which the rest of the population must cope, and that these problems may be diagnosed and treated less well by a necessarily highly focused rheumatologist. Recognizing that the training and experience of the providers will be an important variable in any comparison of health care delivery models, the committee made generalist-subspecialist issues one of the major segments of its workshop. Research, Education, and Training The charge to this committee focuses very explicitly on clinical practice and how it may differ as a function of the organization and financing of the health care plan in which it is delivered. The committee nevertheless believes that it would be short-sighted to ignore the possibility that the longer-term well-being of persons with RA and SLE might be differentially affected by changes in the care system that have had no measurable short-term impact. The current emphasis on cost containment and market competition has already raised alarms in academic medical centers, where teaching and research functions are partially funded by clinical income. Any change in the numbers or types of physicians or other health care providers will take many years to accomplish, given the status quo and the length of the educational pipeline, and it will take just as long to reverse should the change prove maladaptive. As Robert Meenan points out later in this report, there is no reason to think that research into rheumatic diseases will be affected differently from research on other diseases as managed care and managed competition evolve or that rheumatology will fare any differently than other medical subspecialties. The remarkable improvements in the mortality and morbidity of RA and SLE patients over the last 20 years, however, suggest that any comparison of health care models ought to extend beyond cost-effective delivery of today's best practices and include the likely effects on the discovery and implementation of tomorrow's best practices. 38   Ad hoc Committee on Costs and Outcomes of Rheumatologist Care (1995). Specialty Care for Chronic Disease in Integrated Health Care: The Role of the Rheumatologist in Arthritis, Rheumatic, and Musculoskeletal Disease Management. Atlanta: American College of Rheumatology.

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--> The Workshop The remainder of this report, with the exception of Conclusions and Recommendations, consists of edited proceedings of the workshop conducted by the committee on May 16, 1996, in Washington, D.C. The report is divided into sections, the central features of which are prepared addresses by invited experts selected by the committee at a planning meeting in February. Each invited talk is preceded by a brief introduction written by a committee member and followed by one or more brief commentaries from predesignated "reactors" and by excerpts from the lively discussion that ensued among speakers, reactors, committee members, and a small number of other invited participants. Brief biographies of the committee members and speakers, and a list of other participants, are included in the appendix material. The invited speakers and reactors were all asked to check the text for accuracy, and the opinions expressed are solely those to whom they are attributed. The final section is the work of the committee alone and brings together the committee's conclusions and recommendations.