In the United States, health care has been taken over by managed care organizations, some commonly referred to as Health Management Organizations or HMOs.
In the Journal of Rehabilitation, Alston quotes managed care as defined by Drasner and Michaels as "any formalized approach to medical service provision that favorably affects the price of services, the site at which services are received, or their utilization. It is comprehensive and involves planning and coordinating care, educating patients and providers, overseeing quality of care, and monitoring costs. (Lepler, 1995) Economic control is a central theme in managed care. Familiar practices of managed care include minimal access to specialists, limited access to hospital beds, and increased prepayment and copayment.” Managed Care consists of the primary care physician, utilization reviewers, the health management organization and payment capitation.
Unfortunately, there are many reported limitations to managed care in health care policy. These limitations include: lack of choice, reduction in high cost services, lack of home care that forces nursing home enrollment, and higher risk of complications and death due to limitations on care because of cost.
These are true for everyone, but when you factor in the care needed for people with disabilities, the issues become compounded. People with disabilities may require special health care needs, higher health care cost and are not as likely to be able to acquire insurance. Managed care covers those who are healthy and need average care. The severely sick, disabled or aged do not receive adequate services and practitioners cannot offer the extra care and time that the severe cases require, due to cost management.
The need for cost control in health care has driven state governments to persuade enrollment in Managed Care plans. Government programs are privatizing health care by states contracting with health care providers. "Oftentimes these agreements result in economic limits on services for recipients such as persons with disabilities." (Alston)
On Frontline, in The High Price of Health, a television broadcast that aired April 14, 1998, a proponent of managed care, Dr. Malik Hasan, stated the concept of managed care as being incontestable. The concept in his words is to “manage the care in the most efficient manner, bringing the best quality and the lowest cost." However, in reality, what happens is as was reported in this program, “managing money and rationing the care...Not-for profit HMO’s end up competing with for-profit HMO’s."
The DHFS is proposing using the Care Management Organization (CMO) and a Prepaid Health Plan (PHP). The CMO will be responsible for dispensing the Long Term Care benefit. The CMO’s task has been defined as "managing support and service in a cost effective manner." (DHFS)
How can the disabled community support this movement in long term care?
In the DHFS proposal for Wisconsin Long Term Care Redesign, the CMO may be public or private, but must not be for profit. The CMO will receive a fixed monthly payment per person enrolled in the program. These payments are not supposed to limit or expand a person’s care. The CMO is supposed to take into consideration consumer needs and preferences, and consumers are intended to take part in the care plan. In other words, consumers should have a choice.
During the initial CMO demonstration projects, the DHFS is offering counties/tribes to phase people who require comprehensive level of care, into the CMO by including voluntary enrollment beginning with people who meet COP-W or CIP1B eligibility standards. Phase 2 would allow eligible people on the wait list for COP and HCBW and new applicants and people who require intermediate level care. Most critical components of Family Care will be the development of the linkages with acute and primary care providers.
People who volunteer into the project will only be allowed to transfer back to their regular slot, if there are slots available in the county’s regular allocation. DHFS hopes this will not be necessary as existing COP choices are included in the new CMO. Differences between the two programs are supposed to be in favor of the positive on the CMO from the consumer point of view. The CMO is supposed to offer “less fragmentation of service delivery, better health care through improved linkages with health care providers." (DHFS) Eventually however, the only way to receive the long term care benefit will be by optioning for the CMO.
Many experts have written on the use of managed care policy in the present health care system. In addition they have written on the terrible consequences managed care policy has had for people with disabilities. There are published reports on existing trials that have shown that managed care does not serve individuals adequately.
In For Patients, Not for Profits Dr. David U. Himmelstein, M.D. and Steffie Woolhandler, M.D. wrote about managed care in the health care industry. “Listening, learning and caring give way to deal-making, managing and marketing." They report that healthy HMO members may well be satisfied by their care but that poor sick patients are less likely to be diagnosed, receive less care, end up in nursing homes, become disabled by their illness and run a higher risk of dying. “Patient comfort, the special needs of the ...disabled are ignored if they conflict with the calculus of profit." This is happening without the consent of consumers or their doctors and that consumers have no voice in the outcome. They feel that medicine should remain noncommercial and that the American people, if informed, would opt for nonprofit national health insurance which costs less, is more efficient and offers better care as shown in other nations who have adopted it.
George Anders writes in Health Against Wealth: HMOs and the Breakdown of Medical Trust that there is a dissatisfaction of the American people with HMOs and that we are asking for more regulation of HMOs. There should be better care for severely sick people, but the HMOs claim they need to raise the cost of premiums to accommodate those changes. “A proposed bill in the US Congress is the Patient Access to Responsible Care Act, introduced by Rep. Charlie Norwood, a Georgia Republican and licensed dentist who argues: If we can protect trees and animals, why can’t we protect patients?" (Anders) George Sanders finalizes with, “managed care may be a lot like the Southern California freeway-- a system that no one really likes, but that everyone puts up with." (Anders)
In the Managed Care for people with disabilities.(Disability and Health Care Policy: Medical Coverage, Service Provision and Professional Preparation), in the Journal of Rehabilitation, July-Sept. 1997, Douglas C. Huntt and Bruce S. Growick report on the concerns of the disabled community in regard to the quality of health care versus the cost in the managed care system. They outline several actions that people with disabilities and advocacy organizations should pursue to ensure the right to quality health care. Constructive recommendations are made, for managed care plans:
In addition, they write, if people with disabilities would receive care in a timely and appropriate manner, future costs would decrease. Managed care organizations should be required to meet standards and quality assurance, and be held liable for their responsibility of care toward people with disabilities. Also, they point out the incongruity of the Managed Care system in regard to the basis of cost effectiveness and efficiency which may not be inherently possible in a system that should be based on “fundamental human needs," nor toward the trend in fostering independence for people with disabilities in policies for health care and rehabilitation, and the reduction of management in peoples lives. “Neither altruism nor cost-effectiveness should be an excuse for usurping the fundamental right of independent choice and living for every American." (Huntt and Growick)
Because of the incongruity of the managed care systems in health care and issues such as limited care and choice, advocacy organizations for the disabled have voiced their concerns in the use of managed care for people with disabilities. Their concern is that though the proposal offers consideration of consumer needs, will there be enough quality assurance, standards, legal and due process requirements in place to be sure that people with disabilities will be adequately served.
The DHFS has offered three consumer rights provisions during the demonstration projects:
Other CMO consumer protection policies: are to be built into the new system. These are proposed to be similar to those currently in place yet improved because of specific performance standards and advocacy. Ombudsman, legal and lay advocacy and peer support organizations will also be supported. CMO’s will be required to monitor themselves for quality improvement and performance. All this still seems dependent on the ability of the CMO and the state to incorporate the voice of the consumer on planning boards, quality assurance teams etc. Self monitoring does not seem enough.
Managed care in health care policy does not appear to serve people with disabilities adequately. It is incongruous with the needs of the disabled. Timely, up front, quality service may well help a child or a young person with disabilities become a productive member of society. To jeopardize this future on the basis of present cost effectiveness and efficiency is to undermine our society.
Standards of treatment leave the disabled on the fringe and in jeopardy. "The expenditure of appropriate rehabilitative therapies, services, and assistive technology devices today can substantially reduce secondary, expensive conditions tomorrow while maintaining the integrity of the medical community. In addition, a comprehensive, wraparound, community-based orientation, including personal care assistance, can be an excellent investment and a viable alternative to costly institutional care." ( Huntt and Growick) "Even though people with disabilities often need expensive and special health care services and do not necessarily "fit" within a fiscal scheme of cost efficient services, they should be given equal access and quality health care." (Huntt and Growick)
The elderly and medicare recipients may well be effectively served by managed care. However, we have a responsibility to people with disabilities for their future. There should be items for which we as a society are responsible that are not based on profit, but based on nonprofit. Basic human needs should not be crushed for cost effectiveness.
For the last 20 years or more, rehabilitation was reformed to offer people with disabilities independence, choice, and freedom. These are inconsistent with managed care policy. Managed care does not promote independent choice that is basic to our fundamental rights for freedom. Rehabilitation has advocated for many years independence in the management of life for people with disabilities. With managed care, we would all take a giant step backward. We have seen the positive effects of independent living for people with disabilities.
We need to be reminded of our responsibility as a society.
How can anyone support this movement in Long Term Care policy for people with disabilities?
Frontline The High Price of Health, April 14, 1998.
Alston, Reginald J., Disability and health care reform: principles, practices, and politics. (Disability and Health Care Policy: Medical Coverage, Service Provision and Professional Preparation), Journal of Rehabilitation, July-Sept. 1997.
Anders, George, Health Against Wealth: HMOs and the Breakdown of Medical Trust.
Himmelstein, Dr. David U., M.D. and Steffie Woolhandler, M.D, For Patients, Not for Profits
Huntt, Douglas C. and Bruce S Growick, Managed Care for people with disabilities.(Disability and Health Care Policy: Medical Coverage, Service Provision and Professional Preparation), Journal of Rehabilitation, July-Sep. 1997.
Lepler, M. (1995) Managed Care, capitation, and change raise isssues in nursing leadership. Nurseweek, 8(12), 24-25.
Wisconsin Department of Health and Family Services, Family Care, Re designing Wisconsin’s Long Term Care System, July 31, 1998.
Wisconsin Department of Health and Family Services, Frequently Asked Questions: About the Care Management Organization Demonstration," Volume 2, Enrollment and Disenrollment.
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