Managed Care and Developmental Disabilities: Reconciling the Realities of Managed Care With the Individual Needs of Persons With Disabilities. Dale Mitchell. Homewood, IL: High Tide Press, 1999.
Me and Scarlet O'Hara, we don't like thinking about unpleasant inevitabilities; we want to think about those tomorrow. As Scarlet learned, however, avoidance does not make it go away. I really should know more than I do about managed care, so it was with the guilt of a grade school child who has not done her homework, that I decided to grit my teeth and face this book. I was heartened by the introduction where Mitchell announces his goal: “to make the complicated subject of managed care understandable for managers and professionals in the DD field” (p. xiii) and promises to use ordinary language to make the concepts accessible to nonspecialists, even to err on the side of accessibility over scholarly presentation.
The author's strategy was to divide the topic into two sections. In the first half of the book, Mitchell traces the development of managed care outside the disability sector and in the second half, explores how that history might inform the impending intrusion of managed care into the disability sector. The text is long on facts and figures. The effect is to confirm that managed care is about figures: the bottom line is money. The matter-of-fact tone does two things—one good, the other not so good. On the good side, Mitchell demystifies terms such as carve outs, risk corridors, and capitation that separate those in-the-know from the rest of us. Learning the enemy's language can lessen its power. The not-so-good effect of the tone, however, is that it blunts the emotional response that I think will be necessary to mount the activism needed to prevent the dangerous paths where managed care can lead.
I must admit that I struggled throughout the book to remember that my task was to critique the book and not the subject. I kept wanting to shoot the messenger. Although I tried to separate the two, at the end of the day, the book left me longing for a more morally than tactilely based offensive strategy. In sum, the author suggests that the coming of managed care to long-term disability is probably unavoidable, and so we should make the best of it. It seems to me that buried in the book are powerful arguments that could be used to avoid its inevitability, but they are not taken in that direction. The readers are warned about dangers (e.g., “true differences in quality [between traditional and managed care] may not surface for many years”) but then lulled by statements such as “the existing research certainly casts doubt as to whether the alleged abuses reported in the popular press are as widespread as is commonly feared”(p. 51). I wondered why the author did not take up more fully the arguments he offers.
The book traces the origins of managed care outside the disability long-term care sector but now inserting itself there. The causal factors and the results of that history are more than just background; they are the foundation for a resistance struggle. Mitchell describes managed care in these terms:
Managed care is a collection of procedures and processes used to restrict service utilization and contain cost. (p. 38)
One of the primary goals of managed care is to shift financial risk (typically through some type of capitation) from payers to health plans, providers, and consumers. (p. 194)
Financial incentives are powerful forces favoring under-treatment. (p. 59)
Mitchell outlines the history of managed care's “success” in containing costs, restricting services, and shifting risk:
[Managed care] reduced costs by either eliminating or drastically reducing expensive hospitalization. (p. 131)
Another method to cut costs in the mental health sector was . . . to substitute less expensive labor for more expensive labor. (p. 133)
Managed care plans have been able to use the over-supply [of providers] in most areas of the acute care health sector to obtain deep price discounts from providers. (p. 144)
For each of these “successes,” he provides an argument for why a similar benefit will not be found within the long-term disability sector.
Most states were implementing cost containment strategies in their long-term developmental disabilities Medicaid spending well before managed care started to slow costs in the acute care sector. (p. 164)
[Quoting Ashbaugh & Smith, 1997] “any substantial savings in the developmental disabilities arena must derive from the substitution of less expensive forms of support for more expensive forms of support. These savings are not the sort to be unlocked through the negotiating savvy and power of the MCE [managed care entity]. Rather, they must derive principally from individual planning/budgeting processes where natural supports are found to substitute for paid supports.” (cited on p. 149)
In the long-term developmental disabilities sector providers are scarce, making it difficult for managed care companies to achieve the dramatic cost savings that were common in acute health care. (p. 190)
Mitchell suggests that “the managed care approach used in the acute care system cannot simply be replicated in the developmental disabilities sector without making major accommodations” (p. 160). He suggests that disability advocates demand answers to key questions such as “How should the anticipated savings be used?” and “How much financial risk should be shifted to providers and families?” (p. 160). The premises of these questions, however, are faulty. The first question assumes savings, but what if there are no savings (as his own arguments suggest)? The second question assumes risk should be shifted to families and only asks how much, with little acknowledgement of the enormous unpaid services already rendered by families across the country. Why don't we ask how to shift financial risk away from families? After seeming to build some potent arguments, he then backs away from them. He discourages those who might resist the coming of managed care with the suggestion it would “be wise for providers, families, and others involved with the long-term developmental disabilities system to shift some of their energy from stubborn resistance to preparing for the inevitability of the growth of influence of managed care” (p. 191).
I was troubled by the illogic of the “promise” of managed care. We do not need managed care to get out of institutions; the savings to be gotten from reduced hospital/institutional use have been, or are being achieved, without managed care. The promise of managed care is built on closing the barn door, but most of the horses have already left, and those who have not do not need managed care to tell them the barn is on fire. We cannot get savings from the already underpaid labor pool. Managed care encourages vertical integration (wherein a single entity provides a broad array of different services) and encourages organizing large provider networks to gain leverage in negotiations, both of which advocates have been fighting for years, and the system offers incentives to avoid serving people with greater needs who need it most. Following the logic laid out in the book seems to show why managed care cannot work. Yet Mitchell suggests “a managed care approach, in theory, could bring benefits to the long-term developmental disabilities sector” (p. 140). Although he acknowledges the potential difference between theory and reality, I did not even buy the theory.
I kept thinking about my frustration with phone services as I read the book. Remember how all that deregulation was going to help us as consumers to choose the right services for use as individuals at the best cost? Although I have a PhD, I swear I cannot figure out which is the right service for me and certainly cannot figure out how to get it cheaper. The market place assumption of informed consumers who are free to choose is betrayed by the complexity of the marketing of phone service. Health care is moving (has moved) in the same direction. And as much of a necessity as a phone is, it does not come close to the fundamentals of life supports required by many people with disabilities.
Let us be clear: Managed care is about money and profit and business. The author of this text speaks in the discourse of systems, not system users. It is a discussion of what systems need, not a discussion of what their users need. It is a discussion of costs, not a discussion of health. I longed for a debate of morality and public responsibility. But that would be a different book, written from a different stance. Managed care is not presented as a moral dilemma but a tactical/strategic struggle. I agree with Cushman and Gilford (2000) who suggested that we are “ceding moral authority to disengaged procedure” (p. 992) and “a set of technical maneuvers” (p. 989). The argument given as rationale for any unpleasant decisions is that we only have finite resources (are you as tired of it as I am?), so we cannot do everything for everyone. All the more reason, it seems to me, to prioritize health, as we have safety and security, as one thing we can do for everyone, whereas affordable tickets to the next NFL game is one goal that we cannot achieve for everyone. As Cushman and Gilford went on to say, “managed care alone is not the problem; the problem resides in how people live, respond to the power relations of their social world, distribute resources, and conceive of and pursue the good.” (p. 994).
How people live their lives in the context of their social worlds is the stuff of self-determination. Although in the second half of the book the author frequently refers to the self-determination supports paradigm, he does not sufficiently confront the problem of applying a medical/health model to this different paradigm. Mitchell provides a fair description of self-determination and person centered planning but does not marshal their promise to full advantage. The language of managed care is still one of treatment and objective clinical judgment. As Rioux and Bach (1994) so aptly put it “disabilities is [sic] not measles.” Although they argue in terms of research paradigms, the arguments hold as well for funding paradigms. Comparing managed care and traditional services is comparing apples and oranges. Comparing managed care and self-determination is comparing apples and orchards.
The author does accomplish his mission of increasing understanding of the mechanisms of managed care. Mitchell describes the historical context; he draws comparisons; he raises issues (e.g., rate-setting, quality measurement, financial risk). He defines and demystifies terms, but I still don't get it. Mitchell asks “the critical question—whether health care is a commercial commodity similar to sporting goods and household appliances or an essential public good like fire and police protections” (p. 196). After making numerous arguments that seem to display the flawed logic of the “promise” of managed care, he backs off and concludes with the distinctly uninspired goal of ensuring “that the disruption of managed care on developmental disabilities services is minimized.” (p. 189). The subtitle of the book promises reconciling of managed care and individual needs. The reconciling I heard was acquiescence to the inevitable lack of reconciliation between managed care and individual needs. He left me more scared than before when I hoped my fears were based on lack of understanding.
So Scarlet, we do have to think about this today.