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Examining specialty care
Examining Specialty Care Edward Yelin, PhD
T
he managed care revolution was not supposed to turn out this way. As outlined in Alain Enthoven’s influential, if immodestly titled, book, Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care (1), the medical marketplace under managed competition would operate much like a deist’s vision of the way the world works: a basic, minimal set of regulations would ensure that the playing field was leveled among competing health plans so that they could not succeed by selecting low-risk patients. Then the invisible hand of the marketplace would result in a more efficient provision of health care. Leveling the playing field involves a short-term visible hand of regulation. Thereafter, the ways that health plans tame the medical market would be invisible to the parties involved: consumers (sometimes called managed care lives or patients) and providers (sometimes called contractors or employees or physicians). We have not succeeded in either part of the revolution. Evidence is mounting that the playing field has not been leveled, with substantial selection of low-risk patients and avoidance of high-risk patients (2,3) and concurrent growth in the number and proportion of the US population without health insurance (4). The mechanisms to control costs have become highly visible, and the rules governing care have become increasingly bureaucratic (5,6) and have been the subject of a very public vetting in such venues as the media and federal and state legislatures (7). As of mid-October 1999, the House has passed the most comprehensive of the proposed laws governing managed care plans, the Norwood-Dingell bill (8). The visible hand of Norwood-Dingell applies to both group and individual health insurance (affecting more than 160 million persons), mandates that patients be allowed an independent review by medical experts of decisions denying care and penalizes plans $1,000 per day for failing to comply with the decisions of the reviewers, guarantees access to medical specialists, requires plans to provide coverage for emergency care that a prudent lay person requests, provides for the use of nonplan providers, permits the use of nonformulary drugs deemed medically necessary, and, most visibly, allows patients to sue their health plans in state court.
Am J Med. 2000;108:89 –90. From the University of California, San Francisco, San Francisco, California. Requests for reprints should be addressed to Edward Yelin, PhD, Department of Medicine and Rosalind Russell Medical Research Center for Arthritis, Box 0920, University of California, San Francisco, San Francisco, California 94143-0920. 䉷2000 by Excerpta Medica, Inc. All rights reserved.
The extent to which managed care organizations have based their decisions about how to control costs on evidence about clinical effectiveness is unclear. What is clear is that the public debate about managed care will make it less likely that such decisions will be based on evidence in the years to come. This is unfortunate, because our knowledge in this area continues to increase. Recent studies have addressed the effects of limiting consumers to a restricted panel of providers versus creating incentives to use such a panel, requiring the use of a gatekeeper physician versus allowing self-referral, limiting physicians to an explicit drug formulary, and mandating that specific medical problems be treated by generalist physicians (5,6). The article by Katz and colleagues in this issue of the Journal (9) is part of the growing literature that compares specialties in the treatment and outcome for specific health problems, in this case knee and shoulder pain. The authors report that patients of orthopedic surgeons, rheumatologists, and general internists differed in casemix, but that, after statistical adjustment for these differences, the patients of the three specialties did not differ in the principal outcome measures—pain relief and functional status— during 3 months of follow-up. However, the specialties did differ in their patients’ satisfaction with care: patients of orthopedic surgeons were the least satisfied with the office environment, whereas such patients and those of rheumatologists were most satisfied with the doctor–patient interaction. Finally, not surprisingly, the specialties are creatures of their training: orthopedic surgeons ordered more plain radiographs of the knee and shoulder and magnetic resonance imaging scans of the knee than the other specialists, and rheumatologists performed more joint aspirations and injections. Thus, although the specialties did not differ in outcomes, they did differ in satisfaction, utilization, and cost. Unfortunately, there are no clear-cut patterns to the results of studies that have compared specialties in the treatment of medical conditions, in general, and musculoskeletal conditions, in particular. In the Medical Outcomes Study, for example, no difference in outcomes among specialties was found (10). However, in studies of the outcome of acute myocardial infarction (11,12), stroke (13), asthma (14), and rheumatoid arthritis (15,16), patients of specialists experienced better outcomes than those of generalist physicians. In almost all of these studies, however, specialists used high-cost diagnostic and treatment procedures more frequently than their generalist colleagues, raising the question as to whether any differences in outcome were worth the cost (17). 0002-9343/00/$–see front matter 89 PII S0002-9343(99)00372-1
Examining Specialty Care/Yelin
Assuming for purposes of debate that all of the foregoing studies were well done, it would appear that one can make no general conclusions about the effects of treatment by different specialties on outcomes. Instead, the results vary by condition, suggesting that an inviolate rule limiting access to specialists may harm patients with some diseases, while making perfect sense for other patients. However, there are no randomized trials comparing specialties, and given the difficulty of performing such studies, it is unlikely that any will be done in the foreseeable future. Those of us who have performed observational studies know that statistical adjustment for differences in case-mix is art, not science, and thus that any differences that have been found between specialties may be artifactual. In addition, the results of studies that have compared specialties in the treatment of specific conditions may only apply to one era of care. A recently developed treatment may be rare in the practice of generalists today, common tomorrow. In most comparisons, specialization is considered an all-or-nothing phenomenon. In truth, the completion of several years of fellowship may confer greater benefits than a few months of training in an area, but frequently some training trumps none at all. More importantly, by putting generalists at financial risk for the specialty care that their patients use, managed care organizations have created antagonisms that may interfere with effective consultation among physicians. Indeed, two studies indicate that consultative care achieves better outcomes than treatment by generalists alone (16,18). Thus, the evidence does not support a “one size fits all” rule about the use of generalists or specialists for specific conditions. But the evidence may not mean much, for the debate about how managed care organizations provide care has shifted from the invisible realm of their internal administrations to the visible realm of Congress.
90
January 2000
THE AMERICAN JOURNAL OF MEDICINE威 Volume 108
REFERENCES 1. Enthoven A. Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Reading, MA: Addison-Wesley, 1980. 2. Luft H, Miller R. Patient selection in a competitive health system. Health Aff. 1988;7:97–119. 3. Newhouse J. Patients at risk: health reform and risk adjustment. Health Aff. 1994;13:132–146. 4. Campbell J. Health insurance coverage, 1998. Current Population Reports P60 –208. Washington, DC: US Bureau of the Census, 1999. 5. Weiner J, de Lissovoy G. Raising a tower of Babel: a taxonomy for managed care and health insurance plans. J Health Polit Policy Law. 1993;18:75–103. 6. Jensen G, Morrisey M, Gaffney S, et al. The new dominance of managed care: insurance trends in the 1990s. Health Aff. 1997;16: 125–136. 7. Toner R. Rx redux; fevered issue, second opinion. New York Times Week in Review, October 10, 1999. 8. Pear R. House passes measure to expand rights on medical care. New York Times, October 8, 1999. 9. Katz J, Solomon D, Schaffer J, Horsky J, Burdick E, Bates D. Differences in outcomes of care and resource utilization for knee and shoulder disorders between general internists, rheumatologists, and orthopedic surgeons. Am J Med. 2000;108:28 –35. 10. Greenfield S, Rogers W, Mangotich M, Carney M, Tarlov A. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialists. JAMA. 195;274:1436 –1444. 11. Jollis J, DeLong E, Peterson E, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. NEJM. 1996;335:1880 –1887. 12. Nash I, Nash D, Fuster V. Do cardiologists do it better? J Am Coll Card. 1997;29:475– 478. 13. Petty G, Brown R, Whisnant J, et al. Ischemic stroke: outcomes, patient mix, and practice variation for neurologists and generalists in the community. Neurology. 1998;50:1669 –1678. 14. Freund D, Stein J, Hurley R, et al. Specialty differences in the treatment of asthma. J Allergy Clin Immunol. 1989;84:401– 406. 15. Ward M, Leigh J, Fries J. Progression of functional disability in patients with rheumatoid arthritis: associations with rheumatology subspecialty care. Arch Intern Med. 1993;37:2229 –2237. 16. Yelin E, Such C, Criswell L, et al. Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition. Med Care. 1998;36: 513–522. 17. Goldman L. The value of cardiology. NEJM. 1996;335:1918 –1919. 18. Willison D, Soumerai S, McLaughlin T, et al. Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care. Arch Intern Med. 1998;158:1778 –1783.
T
he managed care revolution was not supposed to turn out this way. As outlined in Alain Enthoven’s influential, if immodestly titled, book, Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care (1), the medical marketplace under managed competition would operate much like a deist’s vision of the way the world works: a basic, minimal set of regulations would ensure that the playing field was leveled among competing health plans so that they could not succeed by selecting low-risk patients. Then the invisible hand of the marketplace would result in a more efficient provision of health care. Leveling the playing field involves a short-term visible hand of regulation. Thereafter, the ways that health plans tame the medical market would be invisible to the parties involved: consumers (sometimes called managed care lives or patients) and providers (sometimes called contractors or employees or physicians). We have not succeeded in either part of the revolution. Evidence is mounting that the playing field has not been leveled, with substantial selection of low-risk patients and avoidance of high-risk patients (2,3) and concurrent growth in the number and proportion of the US population without health insurance (4). The mechanisms to control costs have become highly visible, and the rules governing care have become increasingly bureaucratic (5,6) and have been the subject of a very public vetting in such venues as the media and federal and state legislatures (7). As of mid-October 1999, the House has passed the most comprehensive of the proposed laws governing managed care plans, the Norwood-Dingell bill (8). The visible hand of Norwood-Dingell applies to both group and individual health insurance (affecting more than 160 million persons), mandates that patients be allowed an independent review by medical experts of decisions denying care and penalizes plans $1,000 per day for failing to comply with the decisions of the reviewers, guarantees access to medical specialists, requires plans to provide coverage for emergency care that a prudent lay person requests, provides for the use of nonplan providers, permits the use of nonformulary drugs deemed medically necessary, and, most visibly, allows patients to sue their health plans in state court.
Am J Med. 2000;108:89 –90. From the University of California, San Francisco, San Francisco, California. Requests for reprints should be addressed to Edward Yelin, PhD, Department of Medicine and Rosalind Russell Medical Research Center for Arthritis, Box 0920, University of California, San Francisco, San Francisco, California 94143-0920. 䉷2000 by Excerpta Medica, Inc. All rights reserved.
The extent to which managed care organizations have based their decisions about how to control costs on evidence about clinical effectiveness is unclear. What is clear is that the public debate about managed care will make it less likely that such decisions will be based on evidence in the years to come. This is unfortunate, because our knowledge in this area continues to increase. Recent studies have addressed the effects of limiting consumers to a restricted panel of providers versus creating incentives to use such a panel, requiring the use of a gatekeeper physician versus allowing self-referral, limiting physicians to an explicit drug formulary, and mandating that specific medical problems be treated by generalist physicians (5,6). The article by Katz and colleagues in this issue of the Journal (9) is part of the growing literature that compares specialties in the treatment and outcome for specific health problems, in this case knee and shoulder pain. The authors report that patients of orthopedic surgeons, rheumatologists, and general internists differed in casemix, but that, after statistical adjustment for these differences, the patients of the three specialties did not differ in the principal outcome measures—pain relief and functional status— during 3 months of follow-up. However, the specialties did differ in their patients’ satisfaction with care: patients of orthopedic surgeons were the least satisfied with the office environment, whereas such patients and those of rheumatologists were most satisfied with the doctor–patient interaction. Finally, not surprisingly, the specialties are creatures of their training: orthopedic surgeons ordered more plain radiographs of the knee and shoulder and magnetic resonance imaging scans of the knee than the other specialists, and rheumatologists performed more joint aspirations and injections. Thus, although the specialties did not differ in outcomes, they did differ in satisfaction, utilization, and cost. Unfortunately, there are no clear-cut patterns to the results of studies that have compared specialties in the treatment of medical conditions, in general, and musculoskeletal conditions, in particular. In the Medical Outcomes Study, for example, no difference in outcomes among specialties was found (10). However, in studies of the outcome of acute myocardial infarction (11,12), stroke (13), asthma (14), and rheumatoid arthritis (15,16), patients of specialists experienced better outcomes than those of generalist physicians. In almost all of these studies, however, specialists used high-cost diagnostic and treatment procedures more frequently than their generalist colleagues, raising the question as to whether any differences in outcome were worth the cost (17). 0002-9343/00/$–see front matter 89 PII S0002-9343(99)00372-1
Examining Specialty Care/Yelin
Assuming for purposes of debate that all of the foregoing studies were well done, it would appear that one can make no general conclusions about the effects of treatment by different specialties on outcomes. Instead, the results vary by condition, suggesting that an inviolate rule limiting access to specialists may harm patients with some diseases, while making perfect sense for other patients. However, there are no randomized trials comparing specialties, and given the difficulty of performing such studies, it is unlikely that any will be done in the foreseeable future. Those of us who have performed observational studies know that statistical adjustment for differences in case-mix is art, not science, and thus that any differences that have been found between specialties may be artifactual. In addition, the results of studies that have compared specialties in the treatment of specific conditions may only apply to one era of care. A recently developed treatment may be rare in the practice of generalists today, common tomorrow. In most comparisons, specialization is considered an all-or-nothing phenomenon. In truth, the completion of several years of fellowship may confer greater benefits than a few months of training in an area, but frequently some training trumps none at all. More importantly, by putting generalists at financial risk for the specialty care that their patients use, managed care organizations have created antagonisms that may interfere with effective consultation among physicians. Indeed, two studies indicate that consultative care achieves better outcomes than treatment by generalists alone (16,18). Thus, the evidence does not support a “one size fits all” rule about the use of generalists or specialists for specific conditions. But the evidence may not mean much, for the debate about how managed care organizations provide care has shifted from the invisible realm of their internal administrations to the visible realm of Congress.
90
January 2000
THE AMERICAN JOURNAL OF MEDICINE威 Volume 108
REFERENCES 1. Enthoven A. Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care. Reading, MA: Addison-Wesley, 1980. 2. Luft H, Miller R. Patient selection in a competitive health system. Health Aff. 1988;7:97–119. 3. Newhouse J. Patients at risk: health reform and risk adjustment. Health Aff. 1994;13:132–146. 4. Campbell J. Health insurance coverage, 1998. Current Population Reports P60 –208. Washington, DC: US Bureau of the Census, 1999. 5. Weiner J, de Lissovoy G. Raising a tower of Babel: a taxonomy for managed care and health insurance plans. J Health Polit Policy Law. 1993;18:75–103. 6. Jensen G, Morrisey M, Gaffney S, et al. The new dominance of managed care: insurance trends in the 1990s. Health Aff. 1997;16: 125–136. 7. Toner R. Rx redux; fevered issue, second opinion. New York Times Week in Review, October 10, 1999. 8. Pear R. House passes measure to expand rights on medical care. New York Times, October 8, 1999. 9. Katz J, Solomon D, Schaffer J, Horsky J, Burdick E, Bates D. Differences in outcomes of care and resource utilization for knee and shoulder disorders between general internists, rheumatologists, and orthopedic surgeons. Am J Med. 2000;108:28 –35. 10. Greenfield S, Rogers W, Mangotich M, Carney M, Tarlov A. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialists. JAMA. 195;274:1436 –1444. 11. Jollis J, DeLong E, Peterson E, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. NEJM. 1996;335:1880 –1887. 12. Nash I, Nash D, Fuster V. Do cardiologists do it better? J Am Coll Card. 1997;29:475– 478. 13. Petty G, Brown R, Whisnant J, et al. Ischemic stroke: outcomes, patient mix, and practice variation for neurologists and generalists in the community. Neurology. 1998;50:1669 –1678. 14. Freund D, Stein J, Hurley R, et al. Specialty differences in the treatment of asthma. J Allergy Clin Immunol. 1989;84:401– 406. 15. Ward M, Leigh J, Fries J. Progression of functional disability in patients with rheumatoid arthritis: associations with rheumatology subspecialty care. Arch Intern Med. 1993;37:2229 –2237. 16. Yelin E, Such C, Criswell L, et al. Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition. Med Care. 1998;36: 513–522. 17. Goldman L. The value of cardiology. NEJM. 1996;335:1918 –1919. 18. Willison D, Soumerai S, McLaughlin T, et al. Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care. Arch Intern Med. 1998;158:1778 –1783.