There, in that closed system, they have an opportunity to refer it, which is exactly the opposite of the incentive system in the fee for service, where they could get more money by taking care of these people.

This conference was organized around RA and SLE, but it would have been interesting to add osteoarthritis (OA) to the mix. OA, I think, is an example of where the promulgation of practice guidelines would have a far more profound impact in the Kaiser system, because it is a much more common disease and one that general internists, by and large, follow throughout care. I don't think rheumatologists see any but a handful of these cases and then mainly on a referral basis.

WILLIAM HAZZARD: There appears to me to be one sector of the health care industry that really understands the problem, and that is pharmaceutical companies. Rarely a day goes by that I don't have one of them offering to help me educate my residents on how to give sophisticated care for osteoarthritis, osteoporosis, dislipoproteinemia, and other sorts of problems that are underdiagnosed and undertreated until you get to a subspecialist.

LAURA ROBBINS: There are two studies, one done by the Arthritis Foundation in San Mateo and one done at Cornell, that have looked at patients' beliefs and attitudes in terms of the seriousness of arthritis and whether or not anything could be done about it. In summary, the findings were that it was seen as an old person's disease about which nothing could be done. One wonders if primary care physicians, based on their orientation and training and their own personal belief, do not see arthritis as something that is not a serious disease, and therefore referral patterns and treatments lag relative to diseases such as cancer.

EDWARD YELIN: Hal Holman and I were on the board at the San Mateo project. Indeed, a significant fraction of primary care physicians felt that osteoarthritis and most musculoskeletal conditions were not that difficult or important a problem, so they really didn't pay much attention to these diseases. A minority of physicians thought that these were important problems but weren't going to refer them because they were the bread and butter of their business.

ELIZABETH BADLEY: We have to go all the way to the general public with the message that there are different kinds of arthritis, some of them more serious than others, some requiring a specialist and some not. We need to tell them that there are things you can do for arthritis and that nobody should ever tell you to go home because nothing can be done. There are things we can do, even if only in self-management. I think if we had a more educated public, it would also act as pressure on doctors for referral and better services.

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