Health Practices in Managed Care
Presenter Name: Phillip W. Beatty
Institution: National Rehabilitation Hospital Center for Health & Disability Research
Primary Research Interests: The health and long-term care experience of adults with disabilities
Since 1998, the NRH Center for Health & Disability Research, in collaboration with the Independent Living Research Utilization (ILRU) program, has been engaged in the work of the Rehabilitation Research and Training Center on Managed Care and Disability (RRTC - MCD; NIDRR Grant # H133B70003 - 01B). The question that drove the research and training activities of the RRTC - MCD was formulated in the mid-1990s. During this time frame, disability and rehabilitation researchers were interested in knowing more about the impact of the managed care revolution on the health care experience of individuals with disabilities.
The objective of this presentation is to provide an overview of what we now know about the health care experience of people with disabilities - and about the impact of managed care on that experience.
Two frameworks have generally driven our work on the RRTC-MCD - one substantive, and one methodological.
The Threats and Opportunities of Managed Care
The substantive framework that has driven our research activities is the list of potential threats and opportunities of managed care that were laid out by Janet Sutton and Gerben DeJong in the first year of the RRTC-MCD (Sutton & DeJong, 1998). The aim of the RRTC-MCD has been to determine the extent to which these threats and opportunities are being realized. The primary potential threat of managed care for people with disabilities is reduced access to needed health care across the service delivery spectrum:
"Managed care's financial and risk-sharing arrangements may restrict access to needed specialty services, compromising the health of individuals with disabilities."
- "Managed care's sometimes complicated referral and authorization requirements could pose significant barriers to obtaining needed services."
The primary potential opportunity of managed care, as outlined by Sutton and DeJong (1998), is improved care coordination.
"Coordinated care management practices may avert many secondary conditions that lead to ill health and contribute to functional decline among people with chronic and disabling conditions."
Managed care arrangements may provide greater incentives for the integration and coordination of basic health care and long-term care services for people with disabilities.
- Innovative programs for managing and delivering health care services for people with disabilities are emerging at the state and local levels. These small innovative programs, if successful, have much to teach larger mainstream managed care plans about providing services to individuals with disabilities.
A Mixed-Methods Approach
The methodological framework that has driven the research activities of the RRTC-MCD is a strong mixed-methods approach, illustrated in Figure 1.
Figure 1: Triangulation - Mixed-methods approach utilized in the RRTC-MCD.
In order to determine the extent to which the threats and opportunities of managed care are being realized among people with disabilities, the staff of the RRTC—MCD conducted studies utilizing a wide variety of data collection and analysis strategies.
Nationally representative health surveys.
Our findings from analyses of secondary data sources such as the Medicare Current Beneficiary Survey and the National Health Interview Surveys can confidently be generalized to the national population of people with functional limitations, but the health care items available for analysis are somewhat superficial.
Customized longitudinal health care survey.
To provide a greater depth of information about health services that are most important to people with disabilities, we collaborated with the Missouri RRTC on Arthritis, and the RRTC on Health and Wellness to field our own longitudinal health care survey of people with spinal cord injury (SCI), multiple sclerosis (MS), cerebral palsy (CP), or arthritis. This survey of approximately 900 people from across the U.S. has provided us with detailed information about access to, and satisfaction with a wide variety of health care services, including primary care, specialty care, rehabilitation services, assistive equipment, prescription medications, alternative treatments, and mental health services. This national sample of convenience does not allow us to directly generalize our results to a larger population, but it is the first study to collect in-depth health and health care data from a large group of people with potentially disabling conditions.
Qualitative data collection.
In order to gain a better understanding of health care access problems faced by people with these conditions, we conducted a series of in-depth interviews with a subset of our customized survey sample. We purposefully interviewed individuals who had difficulty obtaining at least three of the aforementioned health care services during our first survey year. Interviewees provided us with details about their difficulties accessing needed health services, and told us about the physical, social, and psychological consequences of these access difficulties. While this very personal data can not be generalized, it allows us to inject real-life meaning into our numerical analyses of the survey projects described above.
The Threat of Sub-Optimal Access is Real, Regardless of Health Plan Type
For the most part, our results indicate that people with disabilities in managed care plans perceive no more access difficulties than their counterparts in traditional fee-for-service plans.
In fact, our analyses of general items in the Medicare Current Beneficiary Survey suggest that Medicare Beneficiaries with disabilities in HMOs, on average, are more likely than their counterparts in traditional fee-for-service plans to report consistent, affordable access to health care (Beatty & Dhont, 2001).
Our customized longitudinal survey of people with CP, MS, SCI, or Arthritis allows us to examine questions of health care access in greater detail – focusing on the wide variety of health care services that are important to people with disabling conditions. Results from this survey suggest that for most services, people covered by managed care plans are no more or less likely to receive the care they need than people covered by fee-for-service plans (Beatty, Hagglund, Neri, et al., 2003).
One important exception is that respondents in managed care are less likely than those in fee-for-service plans to receive needed care from specialists, suggesting that managed care plans have limited provider panels or restrictive referral and authorization processes that limit access to specialists (Beatty, Hagglund, Neri, et al., 2003).
Regardless of health plan type, our survey also found that half of respondents who needed rehabilitation services, and approximately one-third of people who needed assistive equipment, did not receive those services every time they were needed during the survey period (Bingham & Beatty, 2003).
Access Inequities: People With Disabilities in Greatest Need are the Most Likely To Report Access Difficulties, Regardless of Health Plan Type
In our secondary analyses of the Medicare Current Beneficiary Survey, (Beatty & Dhont, 2001), people in the poorest health, and with the most severe disabilities were the most likely to report lower levels of general health care access and affordability. Similarly, analyses of our customized longitudinal survey (Beatty, Hagglund, Neri, et al, 2003), found that people in the poorest health, and those with the fewest financial resources were the most likely to report lack of access to a wide variety of health care services. In both survey efforts, these general indicators of need were stronger and more consistent predictors of sub-optimal access to care than health plan type.
Consequences of Sub-Optimal Access to Needed Health Services
Analyses of our customized longitudinal survey indicate that individuals with spinal cord injury who lack access to primary or specialty care, are at increased risk of subsequently experiencing secondary conditions like urinary tract infections and pressure ulcers (Beatty & Bingham, 2002).
Our in-depth interviews with individuals with disabilities who experienced difficulty accessing multiple health services, have allowed us to understand a wider variety of consequences of poor access to health care. These interviews have provided an in-depth picture of the inter-related physical, social, and psychological consequences of being unable to obtain health care services when they are needed (Neri & Kroll, 2003). Our interviews indicate that sub-optimal access to care is often directly associated with deteriorating health and function, reduced levels of social participation, and feelings of stress and depression. One of our interviewees had the following to say about the difficulties he experienced obtaining health services: "You get to where you feel useless, and you get to where you really don’t want to go on any further. You get tired of fighting the system" (Neri & Kroll, 2003).
Niche Managed Care Plans for People With Disabilities: Realizing the Potential of Disability-Literate Health Care Coordination
Care coordination in mainstream managed care plans. In our in-depth interviews with individuals who had experienced access difficulties, we also asked a series of questions about whether or not people experienced effective care coordination. Despite the promise of enhanced coordination and integrated delivery of services in managed care, analyses of our in-depth interview data suggest that people with disabilities who are covered by managed care plans were no more or less likely than those in fee-for-service plans to experience any kind of care coordination. (Kroll & Neri, 2003).
Regardless of health plan type, interviewees consistently raised the following themes that preclude effective care coordination: (1): interactions with providers who did not have adequate knowledge of their disabling condition; (2) insufficient amounts of provider time and effort spent on coordinating a variety of needed services; (3) lack of communication between providers (Kroll & Neri, 2003).
Care coordination in niche managed care programs for people with disabilities.
In contrast to the lack of coordination experienced by people with disabilities in mainstream managed care and fee-for-service health plans, emerging evidence suggests that managed care plans designed specifically for people with disabilities can coordinate and effectively deliver the complex range of services that are sometimes needed by individuals with disabilities. The most prominent examples of capitated managed care programs designed specifically for people with disabilities are publicly-funded, local-level programs such as Boston’s Community Medical Alliance (Master, 1998; Master, Dreyfus, Connor, et al., 1996), and the Minnesota Disability Health Options (MnDHO) program in the Twin Cities of Minnesota (Tschida & Duff, 2002).
MnDHO is among the first managed health care delivery systems in the country to be developed specifically for working-age adults with physical disabilities. The key feature of the MnDHO program is the health care coordination and support services that are provided to enrollees by AXIS Healthcare, a specialty health coordination entity. AXIS was created by two rehabilitation provider organizations in the Minneapolis / St. Paul area to bring together the expertise of specialty rehabilitation providers and the voice of persons with physical disabilities to capture the opportunities of managed care.
The NRH Center for Health & Disability Research is currently conducting an evaluation of the MnDHO program, and the AXIS model of health care coordination and delivery. The evaluation consists of: (1) a longitudinal survey that captures enrollees’ pre-and post MnDHO health care experiences, and (2) focus group sessions with MnDHO enrollees, and with MnDHO-eligible enrollees who still have traditional fee-for-service health care coverage through Minnesota’s Medical Assistance (Medicaid) program. Preliminary survey results (Beatty, 2002) and focus group results (Beatty & Kroll, 2002) strongly suggest that AXIS Healthcare is having a positive impact on the health care experience of program enrollees. In preliminary analysis of data from the first 20 longitudinal survey respondents from the MnDHO program, we found that:
- 17 of 20 respondents (85%) reported that someone helped them manage the health care services they received only after they had enrolled in the MnDHO program.
- Only 2 of 20 respondents (10%) stated that someone had talked to them about their health needs and created a plan for treatment and services during the year prior to MnDHO enrollment. After enrolling in MnDHO, 18 of 20 (90%) indicated that someone had met with them to determine their needs, and to create a plan for treatment and services.
These quantitative findings are reflected in the focus group data that we collected from MnDHO / AXIS enrollees. The following quotes illustrate the value of health care coordination in the lives of people with disabilities:
- "Myself, I am fairly low maintenance as far as healthcare coordination goes, but my healthcare coordinator is always willing to help me out or go to bat for me if I need something, services, or DME. I’ve had real good experiences with my healthcare coordinators."
- "Post-AXIS, my stress level has been relieved somewhat. I’m able to focus on more vocational and future issues, as opposed to the day-to-day healthcare issues……"
Results from our multi-method analyses of the health care experience of people with disabilities suggest that health and disability researchers must look beyond the managed care / fee-for-service divide for major determinants of health care experience.
The threat of reduced access to care. Our findings indicate that lack of access to health care services is a threat that exists for people with disabilities in both managed care and fee-for-service arrangements. Lack of access to ongoing rehabilitative services and assistive equipment are more likely a function of a serious mismatch between long-term, chronic health care needs experienced by many people with disabilities, and the U.S. healthcare system’s acute care service delivery model. The threat of reduced access to services is most likely to be experienced by people in the poorest health, and those with the most severe disabilities.
The opportunity of enhanced care coordination is not being realized by people with disabilities enrolled in mainstream managed care plans. For the most part, people with disabilities appear no more likely to experience coordinated and integrated delivery of services in mainstream managed care plans than they are in traditional fee-for-service plans.
The experience of niche managed care plans that have been designed specifically for people with disabilities can be instructive to larger mainstream health plans and providers that wish to improve their service to people with disabilities and / or chronic conditions.
- A mixed-methods approach can produce findings that help illustrate the multiple dimensions of complex health care issues faced by people with disabilities.
- Health care reforms aimed at increasing access to services for people with chronic and/or disabling conditions will not resolve access problems if they focus solely on managed care organizations (Beatty, Hagglund, Neri, et al, 2003). Researchers and policy analysts must also seek to revise medical necessity definitions and decision-making processes so that they are more inclusive of services that address long term, chronic needs of people with disabilities (Ireys, Wehr, & Cook, 1999) in both managed care and fee-for-service health plans.
- Training efforts to increase the disability literacy (Palsbo, 2002) of health care providers and health plans is necessary to produce a health care system that meets the needs of people with disabilities.
Beatty, P., Hagglund, K., Neri, M., Dhont, K., Clark, M., Hilton, S. (2003). Access to health care services among people with chronic and/or disabling conditions: patterns and predictors. In Press. Archives of Physical Medicine and Rehabilitation.
Beatty, P. (2002). The Impact of the Minnesota Disability Health Options (MnDHO) Program on the Healthcare Experience of People with Physical Disabilities in Minneapolis / St. Paul: Preliminary Longitudinal Survey Findings. Washington, DC: National Rehabilitation Hospital Center for Health & Disability Research.
Beatty, P., Kroll, T. (2002). The Impact of the Minnesota Disability Health Options (MnDHO) Program on the Healthcare Experience of People with Physical Disabilities in Minneapolis / St. Paul: A Qualitative Analysis. Washington, DC: National Rehabilitation Hospital Center for Health & Disability Research.
Beatty, P., Bingham, S. (2002). Health care access and secondary conditions among people with spinal cord injury. A paper presented at the 2002 Annual Meetings of the American Public Health Association, Disability Forum. Philadelphia, PA. Session 3233. http://apha.confex.com/apha/130am/techprogram/paper_48816.htm
Beatty, P., Dhont, K. (2001). Medicare health maintenance organizations and traditional coverage: perceptions of health care among beneficiaries with disabilities. Archives of Physical Medicine and Rehabilitation. 82: 1009-1017.
Bingham, S., Beatty, P. (2003). Rates of access to assistive equipment and medical rehabilitation services among people with disabilities. In Press. Disability and Rehabilitation.
Ireys, HT, Wehr, E., Cooke, RE. (1999). Defining Medical Necessity: Strategies for Promoting Access to Quality Care For Persons With Developmental Disabilities, Mental Retardation, and Other Special Health Care Needs. Arlington, VA: National Center for Education in Maternal and Child Health.
Kroll, T., Neri, M. (2003). Experiences with care co-ordination among people with cerebral palsy, multiple sclerosis, or spinal cord injury. Submitted to Disability and Rehabilitation.
Master RJ (1998). Massachusetts Medicaid and the Community Medical Alliance: a new approach to contracting and care delivery for Medicaid-eligible populations with AIDS and severe physical disability. American Journal of Managed Care. 4 Suppl: SP90-8, 1998 Jun 25. Master R. Dreyfus T. Connors S. Tobias C. Zhou Z. Kronick R (1996). The Community Medical Alliance: an integrated system of care in Greater Boston for people with severe disability and AIDS. Managed Care Quarterly. 4(2):26-37.
Neri, M., Kroll, T. (2003). Understanding the consequences of access barriers to health care: experiences of adults with disabilities. Disability and Rehabilitation. 25(2): 85-96.
Palsbo, S. (2002). A call for disability literacy. SCI Life. Spring 2002, p. 14-15.
Sutton, J., DeJong, G. (1998). Managed Care and People With Disabilities: Framing the Issues. Archives of Physical Medicine and Rehabilitation. 79: 1313-1316.
Tschida, J., Duff, C. (2002). The AXIS Model: A Disability-Friendly Approach to Managed Health Care. SCI Life. Spring 2002, p. 32-33.