Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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5: Managed Care and Rheumatiod Arthritis: Utilization and Outcomes Over 11 Years
5: Managed Care and Rheumatiod Arthritis: Utilization and Outcomes Over 11 Years
Pages 73-94
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From page 73... ...
5 Managed Care and Rheumatoid Arthritis Utilization and Outcomes Over I} Years 73
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From page 75... ...
2. With regard to the impact of rheumatologists as the main physician care giver, persons with a rheumatologist were significantly more likely to receive treatment with a disease modifying arthritis drug (DMARD)
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Educators and managed care plans must produce knowledgeable physicians and ensure patient access to these skilled care givers. 78MacLean, CH, KK Knight, PG Shekelle, HE Paulus, and RE Brook (1996)
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Finally, because the POP fond of HMO is the slowest-grow~ng fond of managed care and because the structure of the faster-grow~ng forms is not conducive to the conduct of research, I will close by advocating that we graft outcomes studies onto currently mandated quality assurance mechanisms In order to assess the impact of managed care on persons with chronic disease In general and rheumatoid arthritis In particular. 79For a more complete report of this work see Yelin E, L Criswell, and P Feigenbaum (1996)
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From page 78... ...
The largest such endeavor, Medical Outcomes Study (MOS) , found no meaningful difference in outcome between fee for service and managed care for persons with hypertension or non-insulin dependent diabetes.S° With respect to rheumatic diseases, we published results Tom the first two waves of the UCSF panel and reported that utilization and outcomes did not differ for persons with RA in the FFS and PGP sectors.
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From page 79... ...
Each year, a trained interviewer conducts an hour-long survey covering demographic characteristics; signs and symptoms of RA; number and kind of comorbid conditions; a complete inventory of all health care used for RA and other purposes, including the content of ambulatory encounters and hospital admissions; and generic and diseasespecific measures of health and functional status. The survey also collects information about the kind and amount of health insurance.
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From page 80... ...
O ~ - ~,, Health Outcomes The RA panel study includes measures of symptomatology, including extent of pain, stiffness, and swelling; functional status; and global health status. In interpreting the outcomes for those receiving care in FFS and PGP settings, it is important to note that all analyses take into account differences in the baseline characteristics of the two groups, with the results reported presumably representing the long-term effects of the two systems of care.
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From page 81... ...
As a result of these moves, we are able to evaluate differences in the amount and kind of content of care and outcomes for persons with rheumatologists and nonrheumatologists as the main physicians for the RA. In contrast to the comparison between FFS and PGP, we could detect statistically significant differences in functional status, number of painful joints, rating of overall pain, proportion reporting improvement in overall RA status, and proportion experiencing simultaneous improvement in all measures.
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CONCLUSIONS All of the large-scale studies of how persons with discrete chronic conditions fare in FFS and PGP settings fail to detect appreciable differences in outcome. The present study is no exception.
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MANAGED CARE AND RHEUA~1TOID ARTHRITIS 83 we are going to do a systematic evaluation of the newer forms of managed care, we may have to graft studies onto ongoing forms of quality assurance that either are mandated by the Health Care Finance Agency or are necessary if the health plan wants to market its services to large employers. The notion of grafting these kinds of studies onto quality assurance mechanisms makessense for another reason: the cost of replicating the current study comparing FFS and PGPs in multiple forms of managed care would be prohibitive, both because the individual plans may not have sufficient numbers of cases and because the plans change so quickly that it is difficult to follow persons with a discrete chronic condition and their physicians through time.
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Most of the outcome measures here and in other studies are much more measures of disease than of illness, if I can hark back to what Drs. Barondess and Holman said this morning.
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I think this points to the issue of continuing medical education for physicians, particularly those in a primary care situation.
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First, an elementary point is that the costs providing care to enrollees must be kept below the capitated payment rate. There are a lot of ways in which managed care organizations can pursue this.
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From the standpoint of care of the chronically ill, this is potentially the most dangerous cost containment option, because it implies that the organization will benefit from providing poor care to, and allocating resources away from, the chronically ill. I think this is a valid concern because plans may be able to exercise influence on services to the seriously
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From page 89... ...
For one thing, chronic conditions are really pretty widespread in the population. I had a postdoctoral student analyze some data that had been collected from the Employee Health Value Survey, which was done a couple of years ago among employees of Xerox, GTE, and Digital.
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From page 91... ...
If you are a person with a chronic disease and you don't have much that you can control but could join a system with for example, a 10 percent increase in the proportion of people who say their RA has improved, or a 5 percent difference in function, or even a 2 percent difference in joint count if that is something that you could control by the choice of a physician, it appears to me to be something you would do. Capturing that little difference may not be costeffective from the perspective of plan administrators, but from the perspective of a person with the condition, it may be important to them.
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From page 92... ...
multipurpose arthritis center we have started a different type of project, one in which we take a big population of people with rheumatoid arthritis and start defining them on the basis of whether or not they have seen a specialist, rather than starting with a specialist's identifying patients with rheumatoid arthritis. Catherine McLean led this project, which has published data on RA cost in abstract form.84 She looked at a large managed care organization database, where she found some 12,000 individuals coded in the International Classification of Diseases (ICD-9)
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BEVRA HAHN: The study looks at a mix of all kinds of care structures and of people shuffling between one care structure and another. Only about 15 percent of the individuals were in fee for service.
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From page 94... ...
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.
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