G

Medicare Managed Care: Issues for Vulnerable Populations

Joyce Dubow*

Introduction

Recent interest in managed care, a system of care that accepts responsibility for the delivery of health services and the financing of coverage, stems largely from its purported ability to save money.1 In the private sector, employers have turned to managed care to contain steadily rising outlays for employee health insurance premiums. Now, the U.S. Congress also seeks to curb Medicare's rate of growth by restructuring the Medicare program through the introduction of a broader range of health care options that feature managed care arrangements (Balanced Budget Act of 1995). However, the plan to shift the Medicare

*  

Public Policy Institute, American Association of Retired Persons, Washington, D.C.

1  

A definitive conclusion on whether managed care generates true savings must rest on whether the rate of growth of health expenditures is reduced over time. In the Medicare program, there is evidence that HMOs can produce savings, but these have not been passed along to the federal government. To generate savings to Medicare from expanded enrollment in HMOs, changes in Medicare's enrollment conditions and payment system for HMOs would have to be made (Congressional Budget Office, 1995).



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--> G Medicare Managed Care: Issues for Vulnerable Populations Joyce Dubow* Introduction Recent interest in managed care, a system of care that accepts responsibility for the delivery of health services and the financing of coverage, stems largely from its purported ability to save money.1 In the private sector, employers have turned to managed care to contain steadily rising outlays for employee health insurance premiums. Now, the U.S. Congress also seeks to curb Medicare's rate of growth by restructuring the Medicare program through the introduction of a broader range of health care options that feature managed care arrangements (Balanced Budget Act of 1995). However, the plan to shift the Medicare *   Public Policy Institute, American Association of Retired Persons, Washington, D.C. 1   A definitive conclusion on whether managed care generates true savings must rest on whether the rate of growth of health expenditures is reduced over time. In the Medicare program, there is evidence that HMOs can produce savings, but these have not been passed along to the federal government. To generate savings to Medicare from expanded enrollment in HMOs, changes in Medicare's enrollment conditions and payment system for HMOs would have to be made (Congressional Budget Office, 1995).

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--> program so rapidly to managed care raises key questions about this approach, in part because the intended shift is so rapid and also because many are not persuaded that managed care plans are ready for a large influx of vulnerable new members (Braveman and Bennett, 1995). Others caution that the expectations of managed care are unrealistic (Ginzberg, 1995; Mashaw and Marmor, 1995; Meyer et al., forthcoming). Unlike their younger counterparts, Medicare beneficiaries have had relatively little exposure to diverse managed care models. As of January 1996, only slightly more than 10 percent, or approximately 4 million individuals, have been enrolled in any form of managed care, mainly risk-based health maintenance organizations (HMOs). Enrollment is concentrated in just a few areas. In January 1996, about 50 percent of the Medicare beneficiaries enrolled in risk-based HMOs lived in just four states, California, Florida, Arizona, and New York (Health Care Financing Administration, Office of Managed Care, 1995a). Furthermore, those beneficiaries who have been enrolled in Medicare HMOs have tended to be healthier and younger than those enrolled in the traditional Medicare program (Brown et al., 1993). In January 1994, only 4.8 percent of Medicare risk enrollees were disabled (compared with approximately 11 percent in the traditional Medicare program) (Health Care Financing Administration, Office of Managed Care Operations and Oversight Team, 1995b). Finally, a recently released survey of Medicare beneficiaries (U.S. Department of Health and Human Services, 1995a) indicates that many beneficiaries (64 percent) do not even know if they live in areas where they could currently enroll in a managed care plan—this, in spite of the fact that three fourths of beneficiaries do have such an option. Thus, managed care is unknown or unfamiliar to many beneficiaries. The purpose of this paper is to consider the prospect of managed care enrollment for Medicare beneficiaries, particularly those who are vulnerable. How can such individuals be expected to fare in a health delivery environment that is vastly different from the one that most of them have known and understood? The paper first defines "vulnerable" and presents selected demographic characteristics of such individuals. The experiences of vulnerable individuals in managed care programs is

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--> then considered by examining some of the research literature with regard to medical outcomes, patient satisfaction, and disenrollment. Ways that managed care plans currently organize to treat their vulnerable enrollees are presented, and promising innovations and practices that appear to have potential for the successful treatment of vulnerable or high-risk persons are highlighted. Finally, the unique responsibility of public (versus private) purchasers to safeguard the interests of Medicare and Medicaid beneficiaries is identified and the protections that are needed by vulnerable populations enrolled in managed care plans are described. Definition of Vulnerable The changing demographic characteristics of the Medicare population will have a profound effect on the future of the program, particularly with respect to expenditures and the provision of services to beneficiaries. As policy makers develop strategies for restructuring Medicare, it is imperative that they take into account the individuals who use and rely on program benefits. Medicare beneficiaries are vulnerable because of age-related physiologic changes, multiple chronic physical and mental conditions, limited social resources, and a limited ability to manage change (Bates and Brown, 1988). Those segments of the Medicare population that are growing will have the greatest needs: the "old old," people of color, those with disabilities such as end-stage renal disease (ESRD), and cognitive impairments. Therefore, delivery systems must adjust to address the unique needs of an older, frailer population. To one degree or another, virtually the entire Medicare population can be considered vulnerable because of its greater need for health care services and the higher health care costs that beneficiaries incur on account of their age, health status, economic status, or disability. To be sure, many of the "young old" are vibrant and healthy. Nevertheless, as a group, Medicare beneficiaries need more health care services, develop more chronic conditions as they age, and on average, have relatively low-incomes and who, but for Social Security and Medicare, would be poor. Therefore, in this paper, "vulnerable populations" are considered Medicare beneficiaries, both aged and dis-

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--> abled, including those dually eligible for Medicaid and Medicare. As of 1994, there were 36.7 million Medicare beneficiaries of whom 32.6 million were aged (age 65 and over) and 4.1 million were disabled (Health Care Financing Administration, Bureau of Data Management and Strategy, 1995). This estimate includes 229,000 persons with ESRD. In 1994, 14 percent of all Medicare beneficiaries were minorities: 8 percent were African Americans, 2 percent were Asian or Pacific Islanders, less than 1 percent were American Indian or Native Alaskan, and 4 percent were of Hispanic origin (who may be of any race) (American Association of Retired Persons/U.S. Department of Health and Human Services, Administration on Aging, 1995). Seventy-four percent of beneficiaries lived in urban areas, whereas 26 percent were from rural areas. The racial compositions of those living in urban and rural areas were similar, with whites making up about 84 percent of the beneficiary population in urban areas and 87 percent in rural areas (Health Care Financing Administration, 1995). Elderly populations of color, as a percentage of the total U.S. population, are projected to increase; by 2020, 21 percent of elderly persons are projected to be persons of color; by 2050, 30 percent (American Society on Aging, 1992). Disabled beneficiaries account for a growing proportion of total Medicare enrollees. In 1994, disabled enrollees accounted for 11 percent of all beneficiaries, a proportion that is projected to increase to 17 percent by the year 2010; the ESRD population is projected to double by this date, largely because of improved technology and a greater availability of dialysis machines (Health Care Financing Administration, Office of Research and Demonstration, 1995; U.S. General Accounting Office, 1995a). With respect to their racial composition, 18 percent of disabled Medicare beneficiaries are African Americans. Ten percent of beneficiaries are of Hispanic origin (Adler and Phil, 1995). Age In 1992, 12.7 percent of the U.S. population or 33.2 million people, were 65 years of age or over (American Association of Retired Persons, U.S. Department of Health and Human Ser-

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--> TABLE G-1 Actual and Projected Growth of those 65 and over, 1990, 2030 (percent of total population) Year =65 65-74 75-84 =85 1990 12.6 7.3 4.0 1.3 2030 21.8 12.0 7.1 2.7   SOURCE: U.S. Congress, Senate, et al., 1991. vices, Administration on Aging, 1995). The older population, as a proportion of the total population, has tripled in this century. By 2030, the number of persons over age 65 is expected to grow to 65.6 million, representing 22 percent of the total population (Table G-1). There is an upward trend in life expectancy. The increase in life expectancy since 1970 has resulted from declines in mortality among middle-aged and elderly persons U.S. Congress, Senate, et al., 1991) (Figure G-1). Like the general population, the elderly population is growing older. By 2000, of the 35 million persons who will be 65 years of age or older, half will be between the ages of 65 and 74 and almost half will be age 75 or over (U.S. Congress, Senate, et al., 1991). The population over age 85 is the fastest-growing portion of the population. In 1994, among Medicare beneficiaries, 46 percent were between 65 and 74 years of age; as a percentage of total Medicare enrollees, the number of people in this age group has been steadily declining (Health Care Financing Administration, Bureau of Data Management and Strategy, 1995; Health Care Financing Administration, Office of Research and Demonstration, 1995). Thirty-one percent were between the ages of 75 and 84, and almost 12 percent were age 85 and over, a group whose numbers have steadily been increasing as a percentage of the total Medicare population (Health Care Financing Administration, Bureau of Data Management and Strategy, 1995; Health Care Financing Administration, Office of Research and Demonstration, 1995). In 1994, Medicare expenditures were greatest for the cohort over age 85; Medicare expenditures for this group are projected to increase sixfold from 1987 to 2040 (Schneider

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--> FIGURE G-1 Life expectancy at birth and at age 65, 75, and 85, 1991. SOURCE: U.S. Department of Health and Human Services, 1995d, Table 1, pp. 136-137. and Guralnik, 1990). Of the disabled population on Medicare, almost 35 percent were under 45 years of age, 27 percent were between the ages of 45 and 54, and 38 percent were between the ages of 55 and 64. Health Status Data from the Medicare Current Beneficiary Survey indicate that when asked how each would rate his or her own health compared with the health of others the same age, almost 46 percent of aged Medicare beneficiaries rated their health as excellent or very good, a proportion that is considered "remarkably stable" across all age groups (Adler and Phil, 1995). However, other survey results (Figure G-2) suggest that individual

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--> FIGURE G-2 Self-reported health status, percent distribution of persons by age according to respondent-assessed health status, 1992. SOURCE: U.S. Department of Health and Human Services, 1995d, Table 1, p. 36. perceptions of health may decline with age. Self-assessed health status also differs markedly by disability status and race. Only 17 percent of disabled beneficiaries and approximately 25 percent of African Americans reported their health as excellent or very good (Adler and Phil, 1995; Health Care Financing Administration, 1995). Data from a 1994 National Research Corporation survey indicate that those Medicare beneficiaries enrolled in HMOs report health status similar to those receiving care in the traditional Medicare program. Forty-seven percent of HMO members considered their health status to be excellent or very good, whereas 46 percent in the fee-for-service program considered their health status to be excellent or very good (Group Health Association of America, 1995d).

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--> Disability and Chronic Health Care Problems Medicare beneficiaries have diverse needs and service preferences that range from medical care for those with acute chronic conditions to services that help individuals compensate for chronic health problems or disability. With advancing age, the incidence of acute conditions diminishes as chronic conditions become more frequent (U.S. Congress, Senate, et al., 1991). In 1991, the Institute of Medicine reported that among those age 60 and over, 8 of 10 had one or more chronic diseases or impairments (Pope and Tarlov, 1991). The top 10 chronic conditions for people over 65 years of age in 1989 were arthritis, hypertension, hearing impairment, heart disease, cataracts, deformity or orthopedic impairment, chronic sinusitis, diabetes, visual impairment, and varicose veins (U.S. Congress, Senate, et al., 1991). Chronic conditions are the main cause of disability among elderly persons (Bates and Brown, 1988). Researchers use different measures to assess varying degrees of impairment, in part, on the basis of how well individuals function in the community. The following data illustrate variations in the prevalence of disability in the population over age 65 reflecting three different ways of evaluating impairment from less to more severe. (1) In 1991-1992, almost half of those over 65 years of age had difficulty with or were unable to perform everyday activities such as seeing words and letters, hearing normal conversations, having their speech understood, and climbing stairs without resting. (2) A more limited number, about 22 percent, had difficulty with or needed personal assistance with specific tasks (i.e., instrumental activities of daily living that help them remain in the community), such as keeping track of money, preparing meals, or getting around outside the home. (3) Finally, about 15 percent had difficulty with an activity of daily living (ADL) such as getting in and out of bed, bathing, eating, or dressing (McNeil, 1993). In addition to functional impairments, many older persons also have mental or cognitive impairments. The various forms of dementia that affect behavioral, emotional, and social functioning are the primary mental disorders of elders. Other causes of cognitive impairment in elderly persons include delirium, the

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--> toxic effects of medications, trauma, and psychiatric illness. The prevalence of dementia among those over 65 years of age living in the community is approximately 3 to 6 percent, with the prevalence increasing with advancing age (Callahan et al., 1995). Nationally, in 1991, the total cost for those with senile dementia was estimated at $67 billion (Callahan et al., 1995). Nearly 5 million individuals over 65 years of age experience serious symptoms of depression. However, this estimate may undercount the prevalence of this condition because depression is probably underdiagnosed (Rolnick et al., 1994). There is research indicating that rates of depression are high among chronically ill, older adults (Williams et al., 1995). Approximately 5 percent of older adults have an anxiety disorder, with perhaps 10 to 20 percent displaying anxiety symptoms (Smyer, 1993). Utilization of Services Those over 65 years of age use more health services than younger persons. On average, in 1993, those over age 65 had almost 10 physician contacts compared with approximately 6 visits for those under age 65 (U.S. Department of Health and Human Services, Public Health Service, 1995). Likewise, in 1992, those over age 65 averaged 2,711 hospital days per 1,000 persons compared with about 456 days per 1,000, for persons 0 to 64 years of age (Gabel et al., 1994; Health Care Financing Administration, Bureau of Data Management and Strategy, 1995). Differences in the utilization of health services between younger and older populations appear to hold true in managed care as well. In 1992, HMO members who were group enrollees averaged 3.9 ambulatory physician encounters per year, compared with 7 ambulatory physician encounters per Medicare risk enrollee (Gabel et al., 1994). In 1992, HMO enrollees over 65 years of age averaged 1,295 hospital days per 1,000 persons, compared with 270 days per 1,000 members for HMO enrollees 64 and under (Gabel et al., 1994). Income and Poverty Status In 1994, 83 percent of Medicare spending was on behalf of

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--> those with annual incomes under $25,000, suggesting that Medicare (as well as Medicaid) primarily serves the needs of lower-income individuals (Armstead et al., 1995). In fact, as a group, Medicare beneficiaries are people who have relatively low-incomes. In 1993, 30 percent of all Medicare beneficiaries had annual incomes under $20,000; more than 20 percent had annual incomes under $10,000 (The Public Policy Institute/American Association of Retired Persons, 1995, using Current Population Survey data) (Table G-2). In 1994, the poverty rate for persons over age 65 was 11.7 percent. The threshold used by the Census Bureau to establish poverty status for the elderly is lower than that for other age groups (The Public Policy Institute/American Association of Retired Persons, 1995) (Table G-3). As a result, older persons must have lower incomes than younger persons to be considered ''poor" by the federal government. In 1994, 2.5 percent of elderly persons had incomes under 50 percent of the federal poverty level, 11.7 percent had incomes below 100 percent of the federal poverty level, and almost 18.7 percent had incomes below 125 percent of the federal poverty TABLE G-2 Income of Persons Covered by Medicare in 1993 Family Income in Thousands ($) Age 0-64, % Age =65, % Total, % 0-10 30.4 20.2 21.3 10-20 25.2 30.1 29.5 20-30 17.4 19.2 19.0 30-50 15.9 17.9 17.7 50-75 7.5 7.6 7.6 75-100 2.3 2.5 2.5 >100 1.3 2.5 2.4 Total 100.0 100.0 100.0   SOURCE: The Public Policy Institute/AARP. Compiled from Current Population Surveys, March Supplement, 1994, Bureau of the Census.

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--> TABLE G-3 Threshold Income for Federal Poverty Level, 1994   Elderly Nonelderly Single $7,108 $7,718 Couple $9,976 $8,967   SOURCE: The Public Policy Institute/American Association of Retired Persons, 1995, Current Population Survey Data. level (The Public Policy Institute/American Association of Retired Persons, 1995). Social Security accounts for half or more of annual income for approximately 60 percent of elderly persons. Thirty-two percent of older persons rely on Social Security for 80 percent of their incomes (Health Care Financing Administration, 1995). Medicaid The Medicaid program assists low-income Medicare beneficiaries with premiums, deductibles, and Medicare cost-sharing requirements under the Qualified Medicare Beneficiary program. For those who are eligible, it also covers benefits not covered by Medicare, such as prescription drugs and long-term care. Less than one third of poor elderly persons are Medicaid beneficiaries, and less than 10 percent of elderly people with incomes between 100 and 200 percent of the federal poverty level are covered under Medicaid. In 1995, nearly 5 million Medicare beneficiaries received some assistance from Medicaid (Health Care Financing Administration, 1995). Although only 12 percent of Medicaid beneficiaries are elderly, 28 percent of Medicaid program expenditures are made on behalf of this population; three quarters of this spending goes for long-term care services (The Kaiser Commission on the Future of Medicaid, 1995).

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--> larly important to track the continuity of care across multiple settings, including home health and other long-term-care settings, and to assess the interpersonal aspects of care, such as patient-physician communication. Managed care plans must also be subject to the ongoing review of professional external quality review and improvement organizations. There are those who would substitute accreditation for external review (Balanced Budget Act of 1995). Indeed, many private purchasers rely solely on accreditation as a means of distinguishing among managed care plans. However, the fact that a plan is accredited merely is an indication that it has the systems in place to produce high-quality care. This represents just a point-in-time description of the plan's capabilities. Beneficiaries need assurances not only that systems are in place but also that there are processes to determine whether the structures and systems are actually working in practice. Therefore, there is a need for ongoing external quality review to detect problems that may not be revealed through an accrediting process. Grievance and Appeals Inevitably, in a system that restricts choice and limits care to "medically necessary services," there will be disagreements between the health plan and its enrollees. A critical beneficiary protection is a grievance and appeals process that enables enrollees to receive timely and clear information about the specific reasons for denials of a service or payment and the right to appeal a denial. For vulnerable populations, it is especially important that the methods of communicating information about the grievance and appeals process be tailored to meet their specific needs. Beneficiaries must retain the right to a review by an independent decision maker outside of the managed care plan, using medical expertise when appropriate, and then access to the federal courts. Of critical importance to vulnerable populations is an expedited review process that includes specific deadlines for situations in which failure to receive care or referral for specialized treatment promptly could jeopardize the patient's health or preclude optimal outcomes. These protections are so essential

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--> to beneficiaries that a plan's failure to comply with requirements, including rules that pertain to timeliness, should result in automatic approval of the disputed service or claim. Conclusion For the employed population under age 65, the U.S. health care system has shifted to managed care. As this trend continues, it is possible to contemplate the disappearance of "pure" fee-for-service plans in the private sector. However, in the Medicare program, 90 percent of beneficiaries still receive their care through traditional fee-for-service arrangements. Although this may change over time, it is not yet certain whether enrollment in managed care plans among older Americans will reach the same level as that among individuals in the private sector. There is no indication that HMOs will cease to attract younger and healthier Medicare beneficiaries. The question is whether the more vulnerable beneficiaries will also voluntarily enroll. There are those who believe that current efforts to expand managed care in the Medicare program may in the end result in reduced rather than enhanced choices for beneficiaries, especially for those who are poorer or sicker. "One should not underestimate the importance of changes in Medicare's fee-for-service reimbursement policy for the prospects of managed care. The major revolution in commercial managed care has been driven largely by pricing and restrictions on choice of indemnity coverage, not simply the availability of managed care alternatives" (Lawlor, 1995, p. 16). If only the very sick remain in the traditional program, causing the Medicare fee-for-service risk pool to deteriorate and eventually become economically unsustainable, the cost of fee-for-service care could become so expensive that only those with high incomes will be able to choose this option. Then, the genuine choice between fee-for-service and managed care plans would disappear. If this becomes the case, many Medicare beneficiaries could find themselves in managed care plans whether they want to be in them or not. Those who do enroll in managed care plans are entitled to do so with the confidence that their health and related needs will be met by these plans—that is, that services will be available,

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--> accessible, and affordable. Today, would such confidence be justified? Medicare beneficiaries are substantially different from those who have typically enrolled in managed care organizations. Several of the researchers whose works were cited in this paper observed indications that the plans studied lacked experience dealing with particular types of chronically ill patients or did not understand the importance of certain treatment modalities that are of importance to those with chronic care needs (e.g., Clement et al., 1994; Shaughnessy at al., 1994). Furthermore, the research evidence is inconclusive. Some studies indicate that older individuals and/or those with chronic conditions have fared well, whereas others indicate that the experiences of older, sicker populations have been less than satisfactory. Moreover, the studies that have been conducted have been hampered by the absence of well-defined norms to adequately evaluate plan performance, particularly in the treatment of chronic conditions. It would be imprudent to generalize from the findings because the reported results may have been peculiar to the model type of the plans investigated, the payment arrangements, or the particular market in which the plans were situated. Clearly, a great deal of research is needed before it will be possible to make unequivocal statements, in either direction, about the experiences of vulnerable populations in managed care plans. Regrettably, waiting for research results will not be an option for today's beneficiaries. The U.S. Congress is poised to expand managed care and other options in Medicare in the short term. At the same time, Congress is also intent on achieving ''savings" from the Medicare program. These savings will be realized in both the traditional and managed care programs. Unfortunately, the present payment methodology used to reimburse HMOs is widely recognized as flawed (U.S. General Accounting Office, 1995b). The adjusted average per capita cost methodology does not contain an adequate risk adjuster, thereby giving plans an incentive to "cherry pick" the healthiest risks. The U.S. General Accounting Office (GAO) has identified several promising efforts in the area of risk adjustment but predicts that an effective risk adjuster is not likely to be available in the near future (U.S. General Accounting Office, 1994). This

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--> means that plans will not be properly compensated for their vulnerable members, encouraging them either to avoid enrolling high-cost, high-risk individuals or to refrain from serving such members adequately, if they do enroll. The absence of an adequate risk adjuster underscores the importance of oversight on the part of HCFA to ensure that financial incentives that do not interfere with the provision of appropriate care and to help minimize any perverse incentives the reimbursement methodology might permit. A standardized benefit package would also help to mitigate risk selection. Although many factors may influence physician decision making (e.g., the plan's quality assurance system, the physician's personal ethics, malpractice concerns, and the desire to retain patients [Gold and Reeves, 1987]), recently, the role of financial incentives on physician behavior has been receiving widespread coverage in the media. Several years ago, GAO recognized that, in the absence of proper controls, incentive payments to physicians had the potential to have a negative impact on the quality of care provided to Medicare beneficiaries. At that time, GAO suggested that "the closer financial incentives are linked to decisions about individual patients, the greater the potential threat to quality of care" (U.S. General Accounting Office, 1988). GAO identified four features that were most likely to affect quality adversely: shifting HMO risk to physicians by holding physicians responsible for the cost of all services, distributing incentives on the basis of individual physician cost performance, paying a percentage of HMO savings on patients as incentives, and measuring physician cost performance over a short period of time. It is disturbing that these practices are still commonly found in physician incentive programs of managed care plans. Many are advocating for the disclosure of the financial incentives used by managed care plans. Although this is a start, it is doubtful that most consumers will comprehend the complex arrangements in use. To avoid the possibility of financial incentives interfering with the quality of services provided, HCFA must identify and ban practices that can be detrimental to patients. In spite of these reservations, it must be said that managed

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--> care does have great potential to serve vulnerable beneficiaries. Managed care plans can provide more effective management, coordinate multiple medical and social problems, and exercise greater flexibility to provide the care that beneficiaries might require (Fama and Fox, 1995; Retchin et al., 1992; Tanenbaum and Hurley, 1995). However, as Schlesinger and Mechanic (1993) have noted, "the capacity of a prepaid plan to provide appropriate treatment to enrollees with persistent and severe illness depends to a considerable extent on the way the plan is organized" (p. 129). Those who are vulnerable must be assured that a comprehensive package of safeguards that includes rigorous standards for public accountability, accessible grievance and appeals mechanisms, and skilled professional oversight will be put in place and maintained by HCFA. Better-integrated and better-organized systems of care promise potentially-high-quality and effective care, but only if a commitment is made at the outset to strong quality assurance, a service ethic that cares for the whole person, and outreach to those in the community who are most in need. References Adler, G. S., and M. Phil. 1995. Medicare beneficiaries rate their medical care: New data from the MCBC. Health Care Financing Rev. 16(4):175-187. American Association of Retired Persons, Administration on Aging, U.S. Department of Health and Human Services. 1995. A Profile of Older Americans. Washington, D.C.: The Association. American Association of Retired Persons, The Urban Institute. 1995. Coming Up Short: Increasing Out-of-Pocket Health Spending of Older Americans. April. Washington, D.C.: The Public Policy Institute. American Society on Aging. 1992. Serving Elders of Color: Challenges to Providers and the Aging Network. San Francisco, Calif.: The Society. Armstead, R., P. Elstein, J. Gorman. 1995. Toward a 21st century quality measurement system for managed care organizations. Health Care Financing Rev. 16(4):25-37. Bates, E. W., and B. S. Brown. 1988. Geriatric care needs and HMO technology. Med. Care 26:488-498. Braveman, P., and T. Bennett. 1995. Let's take on the real dragon: Profiteering in health care. J. Public Health Policy 6:261-268.

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