Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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1: Introduction
1: Introduction
Pages 1-16
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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)
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.t, 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)
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Varying combinations of these procedures are used within any one managed care plan or organization. As characterized by Miller and Lutt~ managed care plans include health maintenance organizations or HMOs, preferred provider organizations (PPOs)
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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.
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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.
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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 andlor ameliorate its effects, and occasionally, orthopedic surgery to repair damage or replace nonfunctional or painful joints.
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. A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee for service practices.
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The Medical Outcomes Study found that HMO hospital utilization was 2~37 percent below FFS.'2 Other studies, including the Medicare risk contract evaluation, have shown small and statistically insignificant differences in admissions.'3 This latter finding likely reflects the (1986)
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Among Medicare risk plans, hospital days per enrollee were ~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.~4 ~ an analysis of the 12 (out of 30) most rigorously conducted evaluations of the impact of Medicaid managed care programs, Hurley et al.~5 found that four MCOs decreased in patient use, one increased use and the other five had no impact.
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. Quality of ambulatory care in Medicare health maintenance organizations.
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Prepaid health plan performance slightly trailed that of FFS In the case of female members, but perfonnance of the two types of coverage was of colorectal cancer in Medicare health maintenance organizations. Journal of General Internal Medicine, 5: 110-114.
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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 heals 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)
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These chronic care benefits included unskilled nursing home stays (usually a maximum of 30 days) and personal care, homemaker, and case management services.
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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.
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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 Tom research on other diseases as managed care and managed competition evolve or that rheumatology will fare any differently than other medical subspecialties.
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16 CHANGING HEALTH CARE SYSTEMS AND RHEUMATIC DISEASE 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.
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