11
Commentary on the Day's Papers

John W. Rowe

I have 10 things to say, and I am going to take only one minute for each, which means that my entire presentation will be substantially shorter than some of the three minute presentations of today's reactors.

First, I would agree with that contention of Bob Meenan and others that managed care is not inherently evil, and that, despite the moral hazard associated with the incentive for underuse, it has several attractive design features with respect to patients with chronic diseases such as rheumatoid arthritis or lupus. These include a tendency to decrease the perils of overuse or even misuse of services and the promose of continuity of care. I think of patients with rheumatoid arthritis seeing a different fellow in the clinic of an academic medical center every 6 months for the last 40 years. I am sure that is not the best possible arrangement. Vertical integration of care and more reliance on non-physician resources might be valuable. An increased focus on prevention and rehabilitation will certainly be valuable.

Secondly, we have heard that managed care is changing. As data are presented by individuals who have done very nice studies in this field, they are quick to tell us that their data are 6 months old and therefore may not be relevant to the current situation. We have also heard that many of the managed care entities are increasingly seeing that they need to add some support services and other services specifically for certain chronic disease populations. So, in addition to not being inherently evil, managed care is rapidly changing.

Third, health care, overall, appears to be just as good under managed care as it is when unmanaged. We can cut the pie some way to demonstrate that it is not as good as the old way of delivering care, but overall it seems to be



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--> 11 Commentary on the Day's Papers John W. Rowe I have 10 things to say, and I am going to take only one minute for each, which means that my entire presentation will be substantially shorter than some of the three minute presentations of today's reactors. First, I would agree with that contention of Bob Meenan and others that managed care is not inherently evil, and that, despite the moral hazard associated with the incentive for underuse, it has several attractive design features with respect to patients with chronic diseases such as rheumatoid arthritis or lupus. These include a tendency to decrease the perils of overuse or even misuse of services and the promose of continuity of care. I think of patients with rheumatoid arthritis seeing a different fellow in the clinic of an academic medical center every 6 months for the last 40 years. I am sure that is not the best possible arrangement. Vertical integration of care and more reliance on non-physician resources might be valuable. An increased focus on prevention and rehabilitation will certainly be valuable. Secondly, we have heard that managed care is changing. As data are presented by individuals who have done very nice studies in this field, they are quick to tell us that their data are 6 months old and therefore may not be relevant to the current situation. We have also heard that many of the managed care entities are increasingly seeing that they need to add some support services and other services specifically for certain chronic disease populations. So, in addition to not being inherently evil, managed care is rapidly changing. Third, health care, overall, appears to be just as good under managed care as it is when unmanaged. We can cut the pie some way to demonstrate that it is not as good as the old way of delivering care, but overall it seems to be

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--> pretty good. There are special populations that don't do nearly as well—the elderly and the poor in particular. However, both the Medical Outcomes Study and Ed Yelin's study, as well as Hal Holman's very nice studies on utilization and cost for osteoarthritis all show that overall, outcomes are pretty good in prepaid group/staff HMO settings. However, these special populations—my fourth point—are very, very important. There seem to be two different parts to this and I think both are worth emphasizing. We heard from Karen Davis and again from Mick McGarvey that these populations have access problems, first in getting into and staying in any system, and then, after they are in, they have access problems related to the process of obtaining care within the system. I think those are two different things. Getting in and staying in the health care system is difficult for some individuals, but equally important is getting access to care if, for example, you don't have a telephone or transportation, a network of friends with these things, and so forth. My fifth point is that, as Brad Gray, Karen Davis, and others pointed out, managed care entities are very variable. They are variable with respect to their content, their organization, their incentives, their training, and their results. I think that we should not even talk about managed care entities in general. Those of us in geriatric medicine like to say that the elderly aren't all the same, and that if you have seen one old person, you have seen one old person. We might want to think about managed care programs and entities in that same way, and try not to paint with such a broad brush. I suspect that new models will evolve as well. It seemed to me that some of the data that were presented, and many of the concepts discussed, coalesced around four structural issues, my items six through nine, that are relevant to chronic disease and managed care. The first of these, from what I heard, was practice guidelines. It seems to me that it is important for us to understand that there are at least three different kinds of practice guidelines. There are behavioral practice guidelines, which really were not mentioned but are really important in chronic disease. These are guidelines like "You should exercise," and getting you to understand that you should exercise. Then there are medical practice guidelines: "This is how you should exercise." The third type of practice guidelines are psychosocial, helping people deal with adaptation to chronic illness. These are very specific, and very different, and nowhere more important than in chronic disease. The second structural aspect of managed care I heard about today that is important to chronic disease has to do with information systems. I think these are very important. That should be the front page, because one of the real advantages of managed care is the ability to follow patients. Providers can track medication use, for example, to see if their patients are using narcotics for pain. That should be routine in a good managed care entity with a good

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--> information system. It is a huge advantage to see how often patients are calling in, to see how often they are coming in, to be able to develop those report cards, to feed back the information, and to establish some quality assurance programs. An information system is a very important part of what needs to be done. The third structural element is sustained patient education and support, and I heard two parts to this in different fragments of the discussion. The first part was how important that education is for vulnerable populations. The second is based on some specific data from the ver impressive study of Hal Holman and Kate Lorig on the self-management program for arthritis. This program decreases pain, decreases depression, decreases use of health care resources, and improves function. Such a program is a very important part of sustained management of all arthritis patients. It is probably not provided by many managed care entities, but it really should be. The last structural element is practice redesign, teamwork, changing the way we practice. I loved the example that we heard earlier from the John Wasson study at the White River Junction VA, in which he increased the quality and decreased the cost simply by calling the patients on the phone. What a novel idea. Let me leave you with a recommendation as my final point, number ten. Because it is always good to have something specific to recommend at the end of an day at the Institute of Medicine (IOM), I pondered as I sat there at the edge of my seat all day about what I could say that would be a specific recommendation. How could we do something specific, use our muscle, use our leverage? An idea finally emerged, and I tried it on Karen Davis before she left. She didn't laugh, so I will try it on you. Karen's third recommendation was to try to establish standards for monitoring HMOs and what they do. We talked about the National Committee for Quality Assurance (NCQA) and the Health Plan Employer Data and Information Set (HEDIS) and how we need better, disease-specific measures. It seems to me that there is a better, quicker, market driven opportunity that the IOM might push. The American Association of Retired Persons (AARP) decided two weeks ago that they were going to sell the AARP seal of approval to HMOs. HMOs will be very anxious to get that approval, and they will be willing to pay dearly for it. We should get AARP our view of programs to guarantee access, measure quality, keep track of patients with chronic disease, improve rheumatologists, and so forth. We should get those views written into the requirements that AARP sends out to these HMOs in their requests, demands, or specifications. These HMOs will have to say, this is what we are going to do for patients with RA or SLE in order to get the AARP seal of approval. We can use the market and use our leverage at no cost, take the results of this day and this committee's work and get it incorporated into a program

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--> which might possibly influence a huge number of people. There are more members of AARP than there are citizens of Canada. That is my last point and my only recommendation.