Book Review

Managed Care and the Inner City: The uncertain promise for providers, plans, and communities

N Engl J Med 1999; 341:1940-1941December 16, 1999

Article

Managed Care and the Inner City: The uncertain promise for providers, plans, and communities
By Dennis P. Andrulis and Betsy Carrier. 191 pp. San Francisco, Jossey–Bass, 1999. $41.95. ISBN: 0-7879-4623-0

Can managed care improve health care for the tens of millions of Americans living in our inner cities? The authors of this book believe that it can. Although they describe thoroughly the ways that managed care has thus far failed to realize this promise, they propose a marriage of the “efficiencies and expertise” of managed care with the experience and commitment of traditional safety-net providers. After reading this succinct, well-researched analysis, we were left wondering whether something more than the authors' marriage counseling will be needed to change the dynamics of this turbulent relationship.

Introducing the challenge are the brief stories of Keisha, Rosa, and Jack — patients lost in the maze of managed care. Their complex lives and health problems evoke the myriad issues faced by many hard-working but vulnerable denizens of the invisible underworld of the sick urban poor. Keisha, a single mother for whom Medicaid was discontinued because she earned too much money, enrolls in the minimal-benefit health plan offered by her employer; she now has difficulty obtaining care and medication for her daughter's asthma. Rosa, an immigrant woman who cleans houses 60 hours a week, faces barriers to health care and financial ruin because of her son's diabetes and her own foot surgery. Jack, a disabled man, is transferred from Medicaid fee-for-service care to managed care; he now cannot afford the copayments on his medications for hypertension, so he takes his medication every other day instead of daily. In addition, he has just been notified that the plan will drop all Medicaid members because it is not making a profit as a result of the state's current reimbursement rates.

Underlying these patients' private health struggles are the social effects of poverty and race, exerting what the authors describe as the “urban health penalty.” Homelessness, violence, substance abuse, human immunodeficiency virus infection, and chronic illness — problems compounded by a lack of or not enough insurance coverage, physician shortages, and problems with regard to the quality of and access to health care — are delineated as important features in the ecology of the inner city.

The bulk of the book, however, addresses another part of this ecosystem — the providers who have historically cared for this population. How has managed care affected public hospitals, safety-net clinics, community physicians, and academic medical centers? To answer this question, the authors survey the institutions and then engage in a tortuous balancing act, looking for common ground and hopeful signs amid the growing evidence of problems and failures.

To the very last page of the book, the authors maintain that “the opportunity for significant, positive change to be derived from managed care for those in our cities cannot be overstated.” This hope, of mainstreaming the care of those now on the margins of the health system and of providing continuity of care to those whose access has been episodic at best, all while improving the efficiency and accountability of safety-net services, simply does not mesh with the reality we have experienced in our own city or with the literature or data that the authors review. Instead, we have seen disruptions in the continuity of care (as employers switch to lower-bidding plans and Medicaid plans fold or pull out); limits and barriers to emergency room, inpatient, and specialized care without commensurate increases in access to primary or preventive care; and most perniciously, the demoralization of dedicated health care providers.

The authors describe successful special programs, such as free immunizations, bilingual services, asthma outreach programs, and community-education campaigns, but most appear to be pilot or exceptional programs whose long-term viability is called into question by the book's chapter on financing managed care. Many of these supposedly innovative programs are already standard fare for the public sector. Absent is any equally detailed accounting of the abuses. Abuses may be more the exception than the rule, but they nonetheless illustrate the risks and difficulties inherent in regulating a marketplace with powerful profit-driven suppliers and vulnerable consumers.

Another premise running through the book, never well substantiated, is the notion that managed care is more efficient care. Is efficiency defined as holding down costs by restricting access and giving less care? Does efficiency mean selectively enrolling lower-risk patients and diverting their premiums away from public hospitals or clinics that must care for the sicker patients left behind? If so, then efficiency for the plan is in fact a loss for the community.

Mindful of these dangers and problems, the authors propose an eight-part prescription for building an effective managed-care system for the inner city. Reforms such as better adjustments of reimbursement for case mix, more effective incorporation of safety-net providers into managed-care networks, greater sensitivity to linguistic and cultural differences, and greater support by plans for trauma and burn services, neonatal intensive care units, and public health surveillance functions would certainly be an improvement over the present situation. However, such recommendations fall short, in part because they do not go far enough to have a substantial effect on the problems, but more because they are unlikely to be adopted, as a result of the power, interests, and incentives in the current marketplace.

This book gives us a good look at how managed care works in the inner city, but it sheds little light on how decisions are actually being made. As managed care shifts the locus of power away from these communities to distant corporate boardrooms, it compounds the most debilitating affliction of these communities — the lack of control over health resources and decision making. A lack of insurance adds further disenfranchisement. Needed, instead, is a broader strategy for fair and adequate health insurance coverage, combined with the support of the health care institutions that have long-term commitments to the community.

Gordon D. Schiff, M.D.
Cook County Hospital, Chicago, IL 60612

Susan B. Cahn, M.H.S.
Chicago Department of Health, Chicago, IL 60604