The Evolution and Treatment of Disease Over Time

Over the last century, treatment and understanding of disease, has evolved and reconfigured in response to advances in medical technology as well as social and environmental changes. The interplay among these factors has resulted in the development of different approaches to the organization of care at different points in time.

Pasteur's discovery of germs located disease as specific biological entities that exist outside of the body. Germs, and the resulting medical abnormalities they caused, could therefore be isolated and treated. Development of technological instruments such as the thermometer, EKG, blood pressure cuff, and x-ray produced mechanisms for monitoring normal and abnormal states.1 These technologies standardized not only states of the body but also indicated courses of universal care that would treat illness as discreet episodes. For the first time, the majority of care occurred in hospitals that possessed this highly technological equipment rather than in patients' homes. Each of these shifts reinforced an organizational framework for care that viewed illness as episodic and distinct from other rhythms of life. In addition, the ability to treat disease led to increased life expectancy.

Increased life expectancy and the ability to treat many acute illnesses effectively has resulted in the ability for individuals with chronic conditions such as heart disease and diabetes to live much longer with these conditions. As a result, many physicians have conceptualized both disease and its treatment within a more holistic approach.2 This framework for care focuses not only on the original condition but also the co-morbidities these diseases can cause. Treatment and care recognize the need for broad-based disease management and containment. Rather than viewing illness as episodic, these chronic conditions are viewed as entailing life long treatment through adjustments in diet, exercise, and medication. For those who are already sick, this view of illness moves care from the hospital out to all realms of life.

Currently, patients with chronic illnesses represent the largest consumers of health care dollars, despite attempts at cost containment. Chronic diseases account for nearly 75 percent of total health care expenditures in the U.S., including 76 percent of all hospital admissions, 88 percent of all drug prescriptions, and 72 percent of all physician visits.3 As medical costs continue to rise, the public health community has focused on broad initiatives to reduce not only the incidences of chronic diseases such as heart disease, diabetes, and obesity, but to eliminate the root causes of these conditions at a population level. The New York City Board of Health's recent decision to phase artificial trans fats off the city's restaurant menus is symbolic of this shift in understanding chronic conditions and embodies a movement toward addressing environmental as well as epidemiological concerns.

Beginning on July 1, 2007, New York City Restaurants will be required to remove all artificial trans fat within their food over the next 18 months.4 By banning trans fat from the cities eateries, the New York City Board of Health hopes to decrease the risks of obesity, diabetes, and cardiac conditions in a town where dining out has increasingly become the norm and heart disease is the leading cause of death.5

Several HCFO grantees have explored how treatment for chronic conditions is both conceptualized and delivered. Paul Herbert, Ph.D., of Mt. Sinai School of Medicine, researched whether increased managed care market penetration in a metropolitan area had an effect on the medical care provided for fee-for-service Medicare beneficiaries with diabetes. Herbert found little evidence to suggest a "spillover" effect of managed care market penetration on the quality of care for these beneficiaries. However, he did find that some evidence that quality of care decreased for beneficiaries who remained in fee-for-servicve when the majority switched to managed care.

In another HCFO grant, Mark Doescher, M.D., of the University of Washington examined the relationship between prescription drug coverage and health care costs in a sample of elderly Medicare+Choice enrollees with common chronic health conditions. They found that seniors who lacked prescription drug coverage faced significantly greater non-pharmaceutical-related costs of care than seniors who had drug coverage. In addition, the savings in inpatient (hospital) and emergency department costs approximately offset the costs to the plan of medications for those with a benefit.

Currently, three HCFO grantees are conducting research in this area. Amira El Bastawissi, Ph.D, of the University of Washington is investigating how a Washington State Diabetes Collaborative influences the health and economic outcomes of diabetic patient. David Blumenthal, Ph.D., at Massachusetts General Hospital is researching consumer tools to select high performing physicians within consumer-driven health plans (CDHPs). Specifically, Blumenthal will focus on testing the effectiveness of tools to assist people with chronic conditions to make an informed choice of primary care physician. Marissa Domino, Ph.D., University of North Carolina is studying the impact of supply restrictions for pharmacy benefits in the Medicaid program in North Carolina on medication adherence, health service use, and the cost impact of the change on the Medicaid program. This work is focusing on individuals who use medications for chronic conditions. Additionally, newly funded research from the Public Health Systems Research special topic solicitation considers a range of complex issues related to protecting the population's health.

HCFO Funded Research

Grant No: 58064
Title: Impact of the Washington State Diabetes Collaborative on Patient Health and Economic Outcomes
Institution: Washington State Department of Health
Principal Investigator: Amira El-Bastawissi, Ph.D.
Grant Duration: July 1, 2006 to February 29, 2008

How do the clinics and primary care physicians participating in Collaborative III of the Washington State Diabetes Collaborative affect the health and economic outcomes of diabetic patients? The collaborative combines elements from Collaboratives of the Institute for Healthcare Improvement and the Chronic Care Model developed by Edward Wagner and colleagues. The researchers will capture the later-stage results of the collaborative, "thus offering an impact evaluation of a mature system-change model." In particular, the researchers will explain how different components of the collaborative approach to diabetes care management directly affect health and economic outcomes (utilization and costs). The objective of the study is to better inform health plans, public payers, health care providers, and employers about the economic impact of the collaborative, to inform their quality improvement, benefit design, and payment decisions for diabetic patients.

Grant No: 56527
Title: Involving Consumers in Physician Choice: Making Data into Useable Information for Chronically Ill Patients in Consumer-Directed Health Plans
Institution: Massachusetts General Hospital
Principal Investigator: David Blumenthal, M.D.
Grant Duration: March 01, 2006 - August 31, 2007

What tools will consumers need to help select high performing physicians, within CDHPs? Physician performance data is one of the tools that can be used to help consumers make these decisions. However, there are important opportunities and challenges facing consumer-directed health plans (CDHPs) trying to engage consumers in using physician performance data (PPD). The specific aims of the project are: 1) to develop methods for informing consumers about physician clinical performance; 2) to test the effectiveness of these methods in helping consumers with chronic conditions in CDHPs to make an informed choice of primary care physician (PCP); 3) to explore how consumer characteristics affect their ability to understand PPD and their response to that data. The objective of this study is to understand how and whether PPD can be appropriately and effectively used in CDHPs.

Grant No: 40540
Title: Prescription Benefit Comprehensiveness and Costs of Care in Elderly Persons with Chronic Illness: The Medicare Enrollee Drug Study (MEDS)
Institution: University of Washington
Principal Investigator: Mark P. Doescher, M.D.
Grant Duration: November, 2000 - April, 2003

Is the cost of adding a prescription drug benefit to Medicare offset by a decrease in costs for other health care services? Researchers at the University of Washington examined this question by looking at the effects of prescription drugs on more resource-intensive care. Using a sample of enrollees in a Medicare HMO administered by the Group Health Cooperative of Puget Sound, they tested the following hypotheses: 1) as pharmaceutical benefit comprehensiveness increases, Medicare enrollees will engender higher outpatient pharmacy costs, but lower costs for other outpatient and inpatient services; and 2) that the effects of increasing prescription drug benefits generosity will be amplified for low-income individuals. Their goal was to inform the current debate on Medicare prescription benefits on the possible cost off-setting that could be associated with improving pharmaceutical coverage for the elderly.

Grant No: 56109
Title: Duration Limitations and Adherence to Chronic Medication
Institution: University of North Carolina at Chapel Hill"
Principal Investigator: Marisa Domino, Ph.D.
Grant Duration: January 1, 2006 - December 31, 2006

What is the impact of supply restrictions for pharmacy benefits in the Medicaid program in North Carolina on medication adherence, health services use, and the cost impact of the change on the Medicaid program? (North Carolina Medicaid introduced a 34 days supply limit in July 2001.) Experience in North Carolina will be compared with the experience in Georgia, where there was no change in the days supply requirements. The study will focus on individuals who use medications for chronic conditions in the following categories: anti-hypertensives, anti-diabetic medications, lipid-lowering drugs, anti-psychotics, anti-depressants, and seizure-disorder medications. The objective of this study is to inform state-based and private sector initiatives to constrain pharmaceutical costs, and suggest directions for future research to advance the understanding of how prescription drug policies may affect patient behavior, care processes, and costs in Medicaid beneficiaries and other insured populations.

Grant No: 44201
Title: Managed Care's Spillover Effects on the Quality of Diabetes Care for Medicare Patients
Institution: Mount Sinai School of Medicine
Principal Investigator: Paul L. Hebert, Ph.D.
Grant Duration: January 1, 2002 to July 31, 2003

How does increased managed care penetration affect quality of care in the non-managed care sector? Paul L. Herbert, Ph.D., at Mount Sinai School of Medicine used data from the Physician Survey of the CTS and the National Diabetes Cohort to examine whether efforts to monitor the quality of care in managed care organizations (MCOs) have had similar spillover effects on the non-managed care market - particularly for chronic conditions such as diabetes. Specifically, the researchers examined whether: 1) increased managed care market penetration affects the provision of diabetes-specific preventive care to Medicare beneficiaries in the non-managed care sector; and 2) increased managed care market penetration affects the provision of high-cost medical services to Medicare beneficiaries with diabetes in the non-managed care sector. The study also examined whether managed-care-induced changes in health care use have implications for "avoidable" hospitalizations for persons with diabetes. This study better informs policymakers of the system-wide consequences of health care cost-containment policies that encourage expanded use of managed care.

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1 Rosenberg, Charles E. "The Tyranny of Diagnosis: Specific Entities and Individual Experience," Milbank Quarterly 80, No. 2, (Summer 2002), pp.237-260.

2 Rosenberg, Charles E."Holism in Twentieth Century Medicine," In Christopher Lawrence and George Weisz, eds. Greater than the Parts. Holism in Biomedicine, 1920 1950 (New York and Oxford: Oxford University Press, 1998), pp. 335 55.

3 Tu, Ha T. "Rising Health Costs, Medical Debt and Chronic Conditions" HSC Issue Brief No. 88, September 2004.

4 NYC Board of Health Votes To Phase Out Artificial Trans Fat From New York City's Restaurants, December 5, 2006 (Press Release).

5 Childs, Dan. "Experts: NYC Trans Fat Ban a Healthy Move: Proposal Could Save Lives, and Other Cities May Follow Suit." ABC News, Dec 5 2006.