The unraveling of managed care: recent trends and implications.

The unraveling of managed care: recent trends and implications. During the past two decades, managed care has become the dominantform of health care in the United States Health care in the United States is provided by many separate legal entities. The U.S. spends more on health care, both as a proportion of gross domestic product (GDP) and on a per-capita basis, than any other nation in the world. Current estimates put U.S. . The justification for managedcare was that it would reduce costs without sacrificing the quality ofcare (Dranove, 2000). In recent years, however, a backlash has developedagainst managed care, with many observers raising questions and concernsabout its impact on quality (Randel, Pearson, Sabin Sa��bin, Albert Bruce 1906-1993.American microbiologist and physician who developed a live-virus vaccine against polio (1957), replacing the killed-virus vaccine invented by Jonas Salk. , Hyams, &Emanuel, 2001). After moderating during the 1990s, health care inflationhas accelerated, calling into question the ability of managed care tocontrol costs (Altman & Levitt, 2002; Altman, Tompkins, Eliat, &Glavin, 2003). On many fronts managed care now seems in retreat. BACKGROUND For much of the 20th century, physicians in the United States United States,officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. practiced what Dranove (2000) called "Marcus Welby" medicine,in which general practitioners worked in individual offices, andpatients selected their own practitioners, who diagnosed problems andprescribed treatment. Providers billed patients or insurers after thefact, or retrospectively, on the basis of services rendered. Under this"Marcus Welby" or fee-for-service, system, insurers played arelatively peripheral role. They had no "influence" over"the patient's choice of physician" and did not"negotiate fees, second-guess the appropriateness of the therapy,or seek to improve the quality of the care provided" (Robinson,1999, p. 65). Many observers argued that the fee-for-service approach wasinefficient. One problem was what economists called "moralhazard Moral HazardThe risk that a party to a transaction has not entered into the contract in good faith, has provided misleading information about its assets, liabilities or credit capacity, or has an incentive to take unusual risks in a desperate attempt to earn a profit before the ." According to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. conventional wisdom, moral hazard occurs whenindividuals have no need to assume responsibility for their actions andfail to behave in a rational manner, at least as defined by the market.Under the fee-for-service system, because insurers paid the bill,consumers could afford to be disinterested in or lackadaisical lack��a��dai��si��cal?adj.Lacking spirit, liveliness, or interest; languid: "There'll be no time to correct lackadaisical driving techniques after trouble develops"William J. Hampton. about thecost of health care. In short, they had no economic incentive to forgounnecessary care or shop for the best price (Dranove, 2000). Moral hazard also affected the behavior of providers. Becauseinsurance companies reimbursed providers for whatever the lattercharged, providers had an interest in prescribing more rather than lesscare (Roberts & Clyde, 1993). This does not mean that all providersdeliberately engaged in a conspiracy to inflate inflate - deflate prices. The phenomenonof induced demand Induced demand is the phenomenon that after supply increases, more of a good is consumed. This is entirely consistent with the economic theory of supply and demand; however, this idea has become important in the debate over the expansion of transportation systems, and is often used can be much more subtle. Given the difficulty indiagnosing many medical problems and the lack of evidence supportingmany forms of treatment, the fee-for-service system gave providers anincentive to err on the side of caution by providing more care thannecessary (Dranove, 2000). According to Dranove, although researchersdisagree about the extent to which providers oversupplied care, mostresearchers accept that providers did induce demand. During the 1930s and 1940s, Henry Kaiser Henry Kaiser may refer to: Henry J. Kaiser (1882–1967), American industrialist Henry Kaiser (musician) (born 1952), grandson of Henry J. Kaiser , the well-knownindustrialist, brought attention to the inefficiencies of "MarcusWelby" medicine. Kaiser hired his own physicians and paid them asalary to provide medical care to his work force. After World War II,Kaiser opened this system to the public under the name Kaiser-Permanente(Roberts & Clyde, 1993). Organizations such as Kaiser-Permanenteseemed to have an advantage over the "Marcus Welby" system. Togain access to more expensive and specialized care, patients needed areferral from a primary care physician, who received a salary and had nointerest in recommending unneeded services or treatment (Roberts &Clyde). Because prepaid pre��pay?tr.v. pre��paid, pre��pay��ing, pre��paysTo pay or pay for beforehand.pre��payment n. plans were responsible for the total health oftheir patients and physicians were reimbursed on a capitated basis, theplans had a stake in not only treating patients after they became sick,but also preventing them from becoming sick (Roberts & Clyde). In 1973 Congress, at the urging of the Nixon administration,enacted legislation aimed at stimulating the development of prepaidplans, or what Nixon called health maintenance organizations (HMOs)(Moniz & Gorin, 2003). Significantly, the Health MaintenanceOrganization Act of 1973 (P.L. 93-222) changed the definition of prepaidhealth care. Under the original prepaid plans, physicians workedexclusively for the organization, as either salaried employees or partof a group of providers (Dranove, 2000). However, HMOs referred not onlyto prepaid plans like Kaiser, but also to hybrids known as independentpractice associations, or IPAs (Starr, 1994). Although IPAs "chargecapitation CAPITATION. A poll tax; an imposition which is yearly laid on each person according to his estate and ability. 2. The Constitution of the United States provides that "no capitation, or other direct tax, shall be laid, unless in proportion to the census, or ... rates to subscribers," they allow providers toremain private practitioners and reimburse re��im��burse?tr.v. re��im��bursed, re��im��burs��ing, re��im��burs��es1. To repay (money spent); refund.2. To pay back or compensate (another party) for money spent or losses incurred. them on a (discounted)fee-for-service basis (Starr, p. 35). Moreover, although the originalprepaid plans were nonprofits, the Nixon administration encouragedfor-profit entities to enter the emerging HMO HMOhealth maintenance organization. HMOn.A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, industry (Rothfeld, 1976). Despite this, through the 1970s HMOs remained largely confined tothe West Coast and Minnesota. At the end of the decade, Luft (1978)reported that traditional HMOs, which operated on a nonprofit,staff-model basis, cost less than fee-for-service medicine. Thesefindings, along with continued inflation, and the election of RonaldReagan, helped fuel efforts to move from the open-ended financing offee-for-service to managed care (Moniz & Gorin, 2003). In 1983Medicare introduced a prospective payment system and allowed HMOs toenroll Medicare beneficiaries (Patel & Rushefsky, 1999). In a related development, states began repealing laws that hadprevented insurers from entering into "selective" agreementswith providers (Dranove, 2000). This was critical to the emergence ofmanaged care. According to conventional wisdom, inflation was rooted inproviders' ability to manipulate the fee-for-service system byinducing demand. To change this, insurers needed to shift risk fromthemselves to providers. The repeal of these laws enabled insurers toorganize networks of "preferred" providers, who in exchangefor patients, would reduce their fees and, if necessary, alter theirpractice patterns (Dranove). During the 1980s managed care referred notonly to capitated plans but also to "any" plan that imposedmechanisms, such as utilization review u��til��i��za��tion reviewn.A process for monitoring the use, delivery, and cost-effectiveness of services, especially those provided by medical professionals. and gatekeeping, to"eliminate inappropriate care inappropriate careCare which, according to the RAND Corporation, is defined as '…that for which the expected risks or negative effects significantly exceed the expected benefits for the average patient with a specific clinical scenario.' and reduce costs" (Starr, 1994,p. 38). THE UNRAVELING OF MANAGED CARE During the mid-1990s, health care inflation slowed, and managedcare received much of the credit (Dranove, 2000). As noted earlier,however, the system of managed care includes plans that were verydifferent from the original prepaid plans (Starr, 1994). By 1997 mostindividuals in HMOs belonged to for-profit plans, which had becomeincreasingly concerned with maximizing returns to shareholders (KaiserFamily Foundation The Henry J. Kaiser Family Foundation (KFF), or just Kaiser Family Foundation, is a U.S.-based non-profit, private operating foundation headquartered in Menlo Park, California. , 1998). The spread of for-profit plans raised concernabout the quality of managed care, particularly for less healthypatients, lending support to critics who claim that managed care hasprimarily succeeded by enrolling younger and healthier patients thanfee-for-service plans (Starr). Media reports, as well as individuals' personal experiences,helped spur a backlash against managed care (Blendon et al., 1998). In1997 President Clinton appointed an Advisory Commission on ConsumerProtection and Quality in the Health Care Industry (http://www.hhs.gov/news/press/1997pres/970326a.html). In its final report, the commissionoutlined a series of rights and responsibilities of consumers (http://www.hcqualitycommission.gov/). Congress has heatedly debated this issueand even passed various versions of a patients' bill of rights;despite this, President Bush has not signed a bill into law (Goldstein,2002). The key disagreement revolves around the right to sue managedcare organizations (MCOs) for punitive damages Monetary compensation awarded to an injured party that goes beyond that which is necessary to compensate the individual for losses and that is intended to punish the wrongdoer. . Many states have enactedpatient protection laws, although a recent survey by the National MentalHealth Association found most of these laws to be limited(http://www.nmha.org/ cantmakethegrade/). The strong economy of the late 1990s reinforced opposition tomanaged care. As unemployment fell and demand for skilled workersincreased, many companies began to offer their employees lessrestrictive, and more desirable, health care products (Lesser, Ginsburg,& Devers, 2003). Gabel and colleagues (2001) referred to a"shift from managed care 'heavy' to managed care'light'" (p. 183), as a growing number of individualsenrolled in preferred provider organizations (PPOs), which imposed fewerrestrictions and offered more flexibility than traditional HMOs. Arecent study of 12 metropolitan areas found that health plans areincreasingly reluctant to use traditional "managed caretools," such as selective contracting and risk contracting (Mays,Hurley, & Grossman, 2003). The growth of less restrictive managedcare "has played an important role in rising cost trends"(Strunk, Ginsburg, & Gabel, 2002). A central factor in the "retreat from tightly managedcare" has been the strengthened position of providers, particularlyhospitals, in relation to MCOs (Strunk et al., 2002). This is a historicchange. Part of the challenge for MCOs during the 1980s and 1990s wasforcing hospitals to reduce excess capacity (Duke, 1996; Robinson,1999). In a sense, however, the shoe is now on the other foot. With thenew emphasis on consumer choice, MCOs have become reluctant to excludehospitals from "their networks" (Strunk et al., 2002). Becauseof this and other factors, including a "reduction in excess[hospital] capacity since the mid-1990s" (Devers et al., 2003, p.419), hospitals are increasingly "willing" to defy MCOs when"payment rates are unfavorable." This increased"negotiating leverage" among many hospitals could result inhigher "managed care plan premiums" (Devers et al.). Indeed,hospital costs are now "the leading driver of health care costincreases" (Strunk et al., 2002). MEDICARE AND MANAGED CARE Medicare managed care is also in disarray dis��ar��ray?n.1. A state of disorder; confusion.2. Disorderly dress.tr.v. dis��ar��rayed, dis��ar��ray��ing, dis��ar��rays1. To throw into confusion; upset.2. To undress. (Hurley, Grossman, &Strunk, 2003). Although Congress allowed HMOs to enroll Medicarebeneficiaries in the early 1980s, the number of older adults actuallyenrolled in HMOs grew slowly. In an effort to expand enrollment,Congress, in 1997, created the Medicare+Choice (M+C) program, whichoffered older adults a wide range of choices, including PPOs, privatefee-for-service networks, and medical savings accounts (Moniz &Gorin, 2003). The expectation was that opening Medicare to competitionand the market would not only lower costs but also enable manybeneficiaries to obtain prescription drugs and other benefits notcovered not coveredHealth care adjective Referring to a procedure, test or other health service to which a policy holder or insurance beneficiary is not entitled under the terms of the policy or payment system–eg, Medicare. Cf Covered. by Medicare (Gold, 2001). M+C has failed to live up to the expectations of its creators. Inan "interim" assessment of M+C, Gold (2001) gave the program aD, noting that, since its enactment, beneficiaries' range ofchoices has narrowed and "inequities in benefits and offeringsbetween higher- and lower-paid areas of the country have widened"(p. 121). In a more recent discussion, Gold (2003) noted that M+Cenrollment reached a high in 1999 and has declined since then. In 2002the number of beneficiaries enrolled in managed care was lower than in1997. The number of plans offering M+C products has also declinedsignificantly (Gold, 2003). Gold (2003) identified several factors as contributors to thedecline in M+C enrollment, including a slowdown in the rate of growth ofM+C payments (which was a response to previous overpayments to Medicaremanaged care plans). She also noted that original projections for theprogram were probably unrealistic. Another important factor was thebacklash against managed care, which led to changes in the market thatmade Medicare HMOs less profitable than anticipated and fueledsuspicions about M+C (Gold, 2003). Hurley et al. (2003) also linked theproblems of Medicare HMOs with "a growing backlash against the HMOproduct" (p. 410). Based on the experience of M+C, Gold (2003)concluded that managed care and competition are unlikely to resolve theproblems facing Medicare. Hurley and colleagues are perhaps even morepessimistic. They concluded that "virtually all momentum" forM+C "has been lost" with "enrollment shrinking back tothe levels and locations found in the mid-1990s" (p. 395). THE COURTS AND MANAGED CARE Two recent court decisions provide additional evidence of theunraveling of managed care. In Cicio v. Vytra Healthcare and BrentSpears, MD (http://www.tourolaw.edu/2ndCircuit/200302/ 01-9248.html),the 2nd U.S. Circuit Court of Appeals in New York New York, state, United StatesNew York,Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of decided that theEmployment Retirement Insurance Security Act did not protect MCOs frombeing sued for negligence in state courts. According to the court, MCOsutilization review procedures may be considered "quasi-medical innature" and therefore open to claims of malpractice. This decisionis limited to Connecticut, New York, and Vermont, and the Supreme Courtcould overturn it; however, it could further limit the bargaining powerof MCOs (Albert, 2003b). The second and more important decision addresses state lawsrequiring MCOs to include "any willing provider" on theirpanels. In Kentucky Association of Health Plan, Inc v. Miller,Commissioner, Kentucky Department of Insurance(http://supct.law.cornell.edu:8080/supct/html/ 00-1471.ZO.html), theSupreme Court upheld a Kentucky law requiring MCOs to include all"professionals" who "meet the plans' criteria"(Albert, 2003a). According to the American Medical Association, thisdecision "could give physicians and patients greater strength inholding HMOs accountable for their decisions" ("HighCourt's Clear Thinking," 2003). Although the long-term effectof this decision is unclear, it is likely to erode Erode(ĕrōd`), city (1991 urban agglomeration pop. 361,755), Tamil Nadu state, S India, on the Kaveri River. The city is located in a cotton-growing region, and its industries include cotton ginning and the manufacture of transport equipment. further thebargaining power of MCOs. MCOs can now be required to accept allproviders, which will likely strengthen the bargaining position ofproviders, particularly hospitals. DISCUSSION The managed care revolution of the 1990s has begun to unravel, andhealth care inflation to accelerate (Altman & Levitt, 2002).According to Ginsburg ("Ginsburg Responds ...," 2003):In many ways, we're back where we started inthe early 1990s--health care costs and insurancepremiums are rising at double-digit rates,the number of uninsured people is growingand state budget deficits threaten recent coverageexpansions. Although some observers believe health care inflation may haveslowed in 2002, this is probably mostly the result of cost shifting, asemployers and MCOs increase employees' deductibles and co-payments(Strunk et al., 2001). So the number of individuals without health carecoverage is likely to remain high and to grow. One difference between now and a decade ago is that then managedcare and competition remained largely untested and seemed a possiblesolution to the nation's health care difficulties. This is not truetoday. Altman and Levitt (2002) noted that during the past 40 years,nothing--"neither regulation, voluntary action by the health careindustry, nor managed care and market competition"--has succeeded,at least in any lasting sense, in bringing health care inflation undercontrol. Part of the problem is due to the development of new technologiesand services, which as Aaron (2002) points out, reduce"prices" but result in a surge of new spending. Much of thisexpenditure is inevitable and desirable. However, technology is onlypart of the problem. The simple fact is that the United States spends somuch on health care, particularly in relation to other countries,because health care products and services cost more here than they doelsewhere (Anderson, Reinhardt, Hussey, & Petrosyan, 2003). Inaddition, waste and unnecessary spending burden our health care system(Nichols, 2003). It may be possible to reduce spending by as much as$100 billion a year without affecting quality (Bodenheimer, 2002). A fundamental obstacle to reforming our health care system is lackof political will (Altman & Levitt, 2002; Bodenheimer, 2002).Despite all its difficulties, Medicare has been more successful thanprivate insurers in controlling per capita [Latin, By the heads or polls.] A term used in the Descent and Distribution of the estate of one who dies without a will. It means to share and share alike according to the number of individuals. health care spending andsatisfying consumers (Boccuti & Moon, 2003). Why are we unable toextend Medicare's techniques to the health care system as a whole?Again, the problem largely seems to lie in political opposition, often(although not solely) from entrenched en��trench? also in��trenchv. en��trenched, en��trench��ing, en��trench��esv.tr.1. To provide with a trench, especially for the purpose of fortifying or defending.2. interests (Bodenheimer). Thehistory of President Clinton's Health Security Act demonstrates thedifficulty in building a political coalition capable of enacting healthcare reform (Moniz & Gorin, 2003). CONCLUSION NASW NASW National Association of Science WritersNASW National Association of Social Workers (Washington, DC)NASW National Association of Social WorkersNASW National Association for Social Work (UK)and social workers generally have long played a leading rolein advocating for health care reform (Moniz & Gorin, 2003). Theunraveling of managed care and the growth of the uninsured populationhave again raised awareness of the problems of our health care system.The obstacles to reform are as much political as they are technical.Building a political coalition to enact reform legislation will bedifficult but not impossible. Although public attention has focused on international developmentsin recent months, this could change, as the nation's domesticproblems grow. Several Democratic candidates for president in 2004 havealready developed health care reform proposals (Milligan &Kowalczyk, 2003). Social workers have an important role in raisingawareness of and building support for changing our health care system. One issue that has long divided reform advocates is whether tofocus on incremental change or fundamental reform (Moniz & Gorin,2003). This division loomed particularly large during the battle overthe Health Security Act. This disagreement is a fruitless fruit��less?adj.1. Producing no fruit.2. Unproductive of success: a fruitless search.See Synonyms at futile. one, whichreform advocates can no longer afford. Battles for incremental changeoften involve issues of political power, and advocates can use them asmeans of achieving more fundamental and deeper change (Lardie, 2001). Asdelegates to the 2002 conference of the Universal Health Care ActionNetwork seemed to recognize, incremental reform and fundamental changeare interrelated in��ter��re��late?tr. & intr.v. in��ter��re��lat��ed, in��ter��re��lat��ing, in��ter��re��latesTo place in or come into mutual relationship.in (http:// www.uhcan.org/files/about/conferenceh_2002.html#Outcomes). To fundamentally change our health care system, healthcare advocates, including social workers, must engage in efforts forincremental reform (Gorin, 2000). REFERENCES Aaron, H. J. (2002, January 23). The unsurprising surprise ofrenewed health care cost inflation. Health Affairs, Web Exclusive.Retrieved June 10, 2003, from http://www.healthaffairs.org/WebExclusives/Aaron_Perspectives_Web_Excl_ 012302.htm. Albert, T. (2003a, April 21). High court punches another hole inthe federal law shielding HMOs. AMA News. Retrieved June 10, 2003, fromhttp:// www.ama-assn.org/sci-pubs/amnews/pick_03/ gvl10421.htm. Albert, T. 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Tracking health care costs: Growth accelerates again in 2001.Health Affairs, Web Exclusive. Retrieved June 10, 2003, from http://www.healthaffairs.org/WebExclusives/Strunk_ Web_Excl_092502.htm. ABOUT THE AUTHOR Stephen H. Gorin, PhD, is professor, Social Work Department,Plymouth State College, Plymouth, NH 03624, and executive director, NASWNew Hampshire New Hampshire,one of the New England states of the NE United States. It is bordered by Massachusetts (S), Vermont, with the Connecticut R. forming the boundary (W), the Canadian province of Quebec (NW), and Maine and a short strip of the Atlantic Ocean (E). Chapter; e-mail:sgorin@attbi.com.