that managed care can well serve the majority of the population, such plans may not be suitable for those who make heavier use of the health care system. There is also evidence that elderly persons and those who are disabled are apprehensive about changes that will "force" them into managed care plans. In focus groups conducted in 1995, the greatest concerns expressed by seniors who were not enrollees in managed care plans were the restrictions on physician choice and the perceived lower quality of care in HMOs (Frederick/Schneiders, Inc., 1995).

Advocates for those with chronic illnesses are concerned as well about managed care. "The fear among . . . patients, their families, and advocates is that managed care organizations—prepaid health plans that share the risk of losing money on services-are too inexperienced, too inflexible, and too profit-oriented to meet their special needs" (Families USA Foundation, 1995, p. 1). Others express concerns about the financial incentives in managed care. "Many mental health advocates, who believe that the financial incentives inherent in HMOs, as well as HMOs' lack of experience in providing services to seriously mentally ill individuals, could lead to ineffective or inappropriate care, and a deterioration in the mental health status of these persons" (Christianson and Osher, 1994, p. 899). Still others recognize that although "managed care itself is not the enemy," . . . there are plans that "cut costs by recruiting the healthiest patients, rationing care by making it inconvenient to obtain, and denying care by a variety of mechanisms" (Kassirer, 1995, p. 50). Patients with chronic illness have ''ongoing, often complex and expensive health care needs [that] make them unattractive in a capitated environment" (Safran et al., 1994, p. 1579). These kinds of concerns are raised often and must be taken seriously. The research evidence is limited because managed care has not been the major health delivery system for vulnerable populations. Furthermore, the industry is changing rapidly. Thus, what is known about one particular model may not necessarily apply to the newer managed care entrants. Nevertheless, some of the research evidence may be helpful in predicting how vulnerable populations will experience managed care.



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