• 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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