variety of demonstrations have been mounted with funding from the public and private sectors. These include the Social Health Maintenance Organizations (SHMOs), the Program of All Inclusive Care for the Elderly (PACE), and HMOs established under the Medicare Risk Program (and implemented under the Tax Equity and Responsibility Act or TEFRA). These programs have met with varying success; a largely unanswered question is the extent to which they can be successfully extended to younger populations (DHHS, 1995).

The Office of Disability, Aging and Long-Term Care Policy (of the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services) has developed a comprehensive research agenda on managed care and disability. The committee endorses this agenda and recommends that federal and private funding agencies use it as a template for establishing their individual priorities in this important area of research. Some of the critical research questions identified in the report include the following:

  • What is the impact of different managed care models on access to and use of rehabilitation professionals such as occupational therapy, physical therapy, speech-language therapy, audiology, cognitive therapy, and assistive technologies? If MCO case managers have a good understanding of the service needs and preferences of people with disabling conditions, one can envision systems in which increased access to an appropriate mix of services (i.e., preventive versus curative services and community-based versus institutional care) may result in lower overall costs, increased consumer satisfaction, and better outcomes. Most of the documented and anecdotal evidence accumulated to date, however, suggests that MCOs (particularly private MCOs) are increasingly restricting access to and use of rehabilitation services primarily through the imposition of annual or lifetime caps on use (DHHS, 1995). The impact of these restrictions on consumer outcomes has not been adequately evaluated. Better classification systems and casemix measures are needed to prospectively estimate the services and resources needed to care for people with disabling conditions within an MCO environment. There has been limited success in developing such systems and measures for use in setting hospital reimbursement rates for people with physically disabling conditions. The extent to which these approaches can be used in the context of an MCO has not been evaluated but may hold some promise (Wilkerson et al., 1992; Harada et al., 1993; Stineman et al., 1994). Further research is also needed to evaluate the widely held belief that if MCOs covered needed services on a long-term and ongoing basis that secondary conditions would be avoided and costs savings would be realized through a decrease in hospitalizations


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement