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Neither Prevention nor Cure:
Managed Care for Women with Chronic Conditions

April 1998 - Number Seven

By Julianna S. Gonen, PhD

In large part managed care is based on the notion of using preventive care to keep enrollees healthy, which certainly benefits both enrollees and the health plan (through lower costs). Less certain, however, is how well managed care organizations (MCOs) meet the needs of enrollees with chronic illnesses. As women, and older women in particular, tend to suffer disproportionately from chronic conditions, it is important to examine how well managed care serves women with complex and long-term health needs. This imperative will grow stronger as Medicare and Medicaid continue to increase the enrollment of beneficiaries in managed care plans.

Chronic Illness

Chronic conditions are "long-term conditions that encompass diseases, injuries with long sequelae, and prolonged structural, sensory, and communication abnormalities. They manifest themselves in physical or mental impairments, and they emerge both at birth and throughout the lifespan."1 They often have a significant period of latency before any symptoms are evident. They affect people of all ages: 14% of children and teens, 30% of those age 18-44, 30% of those age 45-64, and 25% of the elderly. Older persons, however, are significantly more likely to experience chronic conditions that are serious and disabling.2

Chronic illness may account for as much as 80% of medical expenses.3 Examples of prevalent chronic diseases are impairments of the arms or legs, arthritis, hypertensive and cardiovascular disease, and diabetes. The prevalence of chronic diseases is in part a byproduct of advances in modern medicine, such as antibiotics and insulin, which have transformed many previously acute and fatal conditions into chronic illnesses.1 Many heart attack sufferers who would have died in earlier times now live with congestive heart failure, and children with cystic fibrosis now regularly reach adulthood. Even early-stage breast cancer and HIV infection are now managed as chronic conditions. Another factor contributing to high rates of chronic illness is the increase in life expectancy, also a result of medical advances; although we live longer, the population over age 85 experiences high rates of chronic illness.

The shift from acute to chronic illness in the U.S. population has significant implications for a health care system based on a curative, acute-care model. We will need to develop new systems for providing chronic care and managed care plans will certainly play a role in defining these new systems. Chronic care refers to the range of medical, social, and emotional support services for people with chronic conditions. It may be provided by caregivers in a personıs home, or in institutions such as nursing care facilities and mental and rehabilitation hospitals.2 In general, it requires different perspectives and approaches than acute care, as chronic illnesses are characterized by fluctuating and unpredictable courses with periods of exacerbation and improvement. Chronic care is "best understood with a biopsychosocial model of illness, one that takes into account the patientsı psychology, preferences, social situation, and other factors far beyond physiologic factors."1 Chronic care approaches include a focus on symptom relief and prevention of further dysfunction rather than cure, techniques that ensure patient participation and empowerment, active roles for patientsı families and social networks, integration of primary and specialty care and the use of multidisciplinary teams, use of both medical and social services, and a greater interdependence between technical quality and patient satisfaction.4

Within the context of chronic conditions it is also important to discuss disability, which presents many of the same issues in terms of long-term management. "Disability" refers to any limitation of physical, mental, or social activity. There is no bright line between chronic illness and disability; many illnesses encompass and lead to disability. There are various types of disability (functional, vocational, learning), as well as different degrees (partial and total) and duration (temporary and permanent). The major causes of disability shift throughout the lifespan. Those under age 18 most commonly experience disability related to mental impairment or illness, asthma, deafness, and speech impairments; young adults suffer from orthopedic impairments; and disability in older adults is caused predominantly by degenerative diseases (such as arthritis and heart disease). Disabilities often lead to secondary conditions, such as musculoskeletal disorders caused by lack of physical activity.2

Chronic Disease and Women

At any age, men have higher mortality rates than women, while women experience higher morbidity rates due to higher rates of acute illnesses and nonfatal chronic conditions.5 Women continue to live longer than men; in 1991, the life expectancy for women was nearly 79 years, compared with 72 years for men. (Black women, however, have a shorter life expectancy than white women - approximately 74 years.6) But although women may live longer, they often do so while suffering from multiple chronic illnesses. Chronic diseases, however, have received less attention in clinical research than acute disorders, implicitly limiting the development of effective treatments. Effective care is also limited by a lack of understanding of the role of non-biologic factors in outcomes5 and, for women, by the traditionally fragmented nature of their health care.

Older women merit special attention when addressing problems of chronic illness and disability, as both are more prevalent in this population. They tend to be taking multiple medications (an average of three over-the-counter and six prescription drugs simultaneously), which makes proper management of their therapeutic regimens critically important, to avoid adverse interactions and medication errors. Fee-for-service Medicare does not cover medications; this has a disproportionate economic impact on women, who have less income than men and require more prescriptions. In general, traditional Medicare has covered the acute illnesses of men better than the chronic illnesses of women.7 Many Medicare MCOs have addressed this inequity somewhat by covering prescription drugs.

"Women's conditions" may be those that affect women only, such as abnormal uterine bleeding, fibroids, endometriosis, vaginitis/cervicitis, and reproductive organ cancers. They may also be conditions that occur in both sexes but are more common in women, including depression, osteoporosis, breast cancer, eating disorders, domestic violence, and incontinence. And only recently has attention been focused on how conditions that affect both women and men, such as infertility, sexually transmitted diseases (including HIV/AIDS), and cardiovascular disease, manifest or are managed differently by gender.8

Several types of chronic disease are particularly important to women, including cardiovascular disease (heart disease, stroke, and atherosclerosis), which has until recently received less attention in women than it has in men. One in three women over age 65 has some form of cardiovascular disease. By 1991 cardiovascular disease already accounted for a greater proportion of deaths in women (46%) than in men (40%), and nearly one third of deaths from heart disease among women occur before age 65. Cardiovascular diseases also account for significant morbidity and disability.6

Cancer is the second leading cause of death for Americans. Many types of cancer, however, can be treated and essentially "cured" if detected in the early stages. The cancers most pertinent to womenıs health include lung, breast, cervical, endometrial, ovarian, and colorectal cancer. For most cancers, the 5-year relative survival rate of black women is lower than that of white women.6

Arthritis and other musculoskeletal disorders are major causes of mobility limitation that are important to women. Rheumatoid arthritis, a chronic inflammatory disease, affects approximately 1% of the population and strikes women two to three times more than men; the prevalence increases with age. Rheumatoid arthritis can lead to disability and decreased life expectancy, particularly among those with severe cases and those of lower socioeconomic status.6

Osteoporosis is an age-related disorder and a significant cause of debilitating bone fractures in postmenopausal women. Women are more likely than men to develop osteoporosis, and white and Asian women more likely than black women. It has been conservatively estimated that 24-25 million women age 45 and over have osteoporosis in the spine. Hip fractures are both debilitating and life-threatening in the elderly, and 75- 80% of these fractures occur in women. Since osteoporosis is not curable, treatment consists of preventing further bone loss through exercise, estrogen therapy, and calcium supplementation.6 Estrogen replacement therapy has been found effective in preventing osteoporosis by reducing bone resorption and slowing postmenopausal bone loss. But estrogen replacement therapy increases the risk of endometrial cancer and possibly breast cancer.

Autoimmune diseases also have a disproportionate incidence in women; 75-80% of patients with autoimmunity are female.9 Lupus, a complex chronic inflammatory disorder, is more common in women than in men, from a 3:1 ratio in childhood to a prevalence rate in adult women 10-15 times higher than in men. Lupus is also four times more prevalent in black women than in white women and twice as prevalent in Hispanic women. It is most common among women of childbearing age. The severest form, systemic lupus erythmatosus, can involve any organ of the body and displays unpredictable periods of activity and remission. Lupus is associated with premature death, most often from renal failure. Therapies include anti-inflammatory drugs, antimalarial agents, corticosteroids, and immunosuppressive drugs.6

Diabetes, a chronic metabolic disease, is the seventh leading cause of death among white women and the fourth among black women. It can be insulin-dependent (type I) or non-insulin-dependent (type II). Type II, or adult-onset diabetes, is more common and can usually be controlled through diet and exercise. Approximately half of women who develop gestational diabetes go on to develop type II diabetes. The prevalence of diabetes increases with age and is greater in black women of all ages. Persons with the disease have an increased likelihood of a shorter life span, as they are more likely to develop other acute and chronic conditions. Women with diabetes have a higher risk of experiencing complications such as blindness, ketoacidosis, and peripheral vascular disease.6

Chronic disease encompasses not only physical ailments but also mental health disorders. Depression in particular has a disproportionate impact on women.10 And while chronic mental health conditions require management in and of themselves, they also interact with other physical conditions, causing significant comorbidity. Those with mental disorders use more general medical services and experience poorer health outcomes overall. There is thus a strong need for better integration of medical and mental health management.

Managed Care and Chronic Illness

Managed care plans are increasingly concerned with issues related to caring for those with chronic illness, in part due to the prevalence of chronic illness and the associated cost burden, and in part due to recent growth in Medicare risk contracting, under which MCOs now care for significant numbers of older persons.11 A study of one HMO found that more than 33% of its enrolled adults in a given year had at least one chronic condition and 14% had two or more, and that costs for this segment of the enrolled population were at least twice the costs for the remaining population. A diagnosis of a chronic condition leads to an increase in costs of anywhere from 80 to 300%, depending on the patientıs age, gender, and chronic condition profile.12 Part of the high cost traditionally associated with chronic illness has been due to suboptimal management. And while marketplace competition may lead MCOs to care for the chronically ill more efficiently and effectively, this incentive may be lacking where competition is high and enrollee turnover is frequent.

Managed care offers several potential benefits for people with chronic illness. The ability to intervene at a system level, rather than solely at the individual patient or provider level, presents significant capacity to overcome the fragmentation of care found under fee-for-service medicine. Because they are under capitation and free from some of the rigid medical necessity rules of fee-for-service Medicare, Medicaid, and commercial indemnity insurance plans, managed care plans can be flexible in providing services, including non-medical services such as transportation and elimination of hazards in the home. Plans also have an incentive to engage patients in greater education about self-care and prevention in order to reduce hospitalization. MCOs also can redirect resources towards non-physician providers who can perform much of the less specialized care.

Innovations in chronic care, however, tend to be sporadic among MCOs, which have not realized their potential for creative care management for those with complex, long-term conditions and disabilities.4 It has also been suggested that MCOs have sought to enroll only healthier individuals, who will cost the plan less in medical expenditures, and avoid those with expensive chronic conditions (a practice termed "cherry picking"). While it is in fact difficult for plans to enroll selectively on an individual basis, because contracts are primarily between plans and employer groups, the benefits package offered may discourage individual members of an employee group from selecting a given plan. Even managed care administrators have conceded that a disincentive exists for plans to develop rich benefits or comprehensive programs for those with costly illnesses, as such options will attract the most costly enrollees.13 The evidence of MCOs successfully avoiding adverse selection is somewhat mixed. Some studies have shown that persons with chronic illnesses under age 65 tend to enroll in HMOs in approximately the same proportion as they enroll in indemnity plans.14 Federal inspectors have begun investigating the practice among Medicare HMOs, which are forbidden by law from cherry-picking, based on a report stating that 18% of Medicare HMO enrollees were pre-screened.15

Once those with chronic conditions join a managed care system, their concerns become more specific, including whether they will have sufficient access to specialists or to physicians with whom they have established long-term relationships, and whether the plan will provide sufficient services to meet their complex needs. If persons with chronic conditions represent only a small proportion of a planıs membership, the plan may not fully embrace the idea of devoting resources to developing the management systems required for those conditions, even though this small proportion of enrollees represents high users of medical services and thus high costs to the plan. Some study results seem to bear out these concerns. A 4-year study of outcomes among the elderly and poor chronically ill found that those patients experienced worse physical health outcomes in HMOs than in fee-for-service systems; mental health outcomes were more mixed.16 A 1997 study of Medicare risk HMOs, which enroll 15% of Medicare beneficiaries, found that while most plans have implemented some specialized services for the elderly, no plans offered enrollees all of the programs recommended by experts to care for chronically ill seniors.15

One of the means by which MCOs manage chronic conditions is known as disease management. The term is subject to some debate: some argue that it is in fact care that is being managed, or that the focus should be placed on health rather than disease. Like many health care terms it lacks precise definition but encompasses several distinct elements, outlined below.

Disease Management

Disease management refers to "a prospective, disease-specific approach to delivering health care spanning all encounter sites and augmenting physician visits with interim management through non-physician practitioners specializing in the target disease."17 This prospective approach redirects intervention efforts toward outpatient settings to the extent feasible and captures data from all sites of care for each patient into a single longitudinal episode. Patients are thus tracked continuously, and more opportunities exist for patient education at encounter sites other than the physician's office or the hospital. Disease management programs typically use non-physician providers to contact patients between physician visits, to conduct morbidity assessments, to provide education and self-care instruction, and to assist with medication compliance. Thus "prevention" refers not to prevention of the disease but to prevention of any exacerbation of the disease.17

Disease management is distinguished from traditional case management in that the emphasis is more on prevention and education than on treatment. Case management encompasses managing patients who often have more than one condition, while disease management focuses on managing patients who are - at least initially - evaluated for just one condition. The two approaches also differ in the use of providers: case managers are for the most part generalist physicians and nurses, while disease management involves specialists and multidisciplinary teams.17

Disease management programs work best within a vertically integrated system, where incentives are aligned among all the systemıs components. This allows coordination across encounter locations that may be physically discontinuous. As in other aspects of managed care, providers are assumed to operate most efficiently if they are at financial risk, where a fee-for-service physician would lack incentives to reduce inpatient and acute care episodes.17

 Carve-outs.  An increasing trend within managed health care has been to "carve out" certain conditions from those covered under a general medical care plan and deliver services for those conditions in a distinct network (a capitated subcontractor), often as a distinct and separate benefit. Proponents of this approach assert that it allows a specialized focus, while detractors argue that it fragments care and undermines the very integration that managed care touts as one of its signature benefits. Although mental health is the area most frequently associated with carve-outs, carve-outs are beginning to appear in other areas as well, such as oncology. Disease-specific carve-outs may prove beneficial for rare diseases within large delivery systems, in which it might be problematic for the general delivery system to divert significant resources from other clinical areas.17 But carve-outs may also not work well because patients often present with more than one disease. The proportion of the general population experiencing comorbidity increases with age, and women have a higher prevalence of comorbidity than men within all age groups over 60. Arthritis and high blood pressure, for example, two of the most commonly reported conditions, are also the disease combination with the highest prevalence (co-occurring in 24% of those age 60 and older).18

Another potential downside to disease management programs is that "the capitated organ-based disease carve-out risks reinstitutionalization of fragmentation,"5 which has long characterized women's health care. Disease management may work well for certain conditions, such as those occurring in younger populations with fewer coexisting conditions, or those that at least initially require intensive and highly technical care, but the primary care provider is usually in the best position to oversee care over the long term and must therefore be involved in disease management programs as early as possible in the patient's course of treatment. It is critically important that disease management programs not disrupt the relationship between the patient and the primary care provider by carving out the management of chronic illnesses.5

 Common Disease Management Targets.  Conditions are considered amenable to disease management if they are high volume and high cost and have a high rate of preventable complications (so that emergency room visits and hospitalizations can be reduced). If they have a short time frame during which alterations in natural history can demonstrate a measurable impact, such as 1-3 years (which coincides with the average time spent in a particular health plan), they are also more attractive to MCOs. Other attributes of ideal disease management targets include chronic outpatient-focused conditions that are common, non-surgical, and can be treated with low technology, as well as conditions for which there is large variation in treatment patterns between different patients and different physicians and high rates of patient noncompliance with the therapeutic regimen (noncompliance that is amenable to change through education). Disease management targets also include conditions for which current care patterns show multiple referrals from primary care physician to several specialists, for which practice guidelines exist or can be developed, and for which consensus on what constitutes good quality can be achieved. Some advanced delivery systems, through weighing the costs and benefits, have identified a short list of diagnoses that seem to demonstrate the largest early impact. They include asthma, congestive heart failure, type I diabetes, aids, and cancer.17

 Pharmaceutical Company Programs.  Many large pharmaceutical companies have developed disease management programs, sometimes through pharmacy benefits manager subsidiaries, built around one of their major products. They offer these programs to MCOs as ready-made packages to manage the care of enrollees with a given condition. Such programs may be useful to smaller plans that have fewer resources to devote to developing comprehensive management programs for chronic illnesses, but they are limited to a particular therapeutic agent that may not always be the drug of choice for a given patient. Commitment to such programs also reduces opportunities to try new products and innovations. Some medical directors have adopted a compromise, in which the drug manufacturer shares some of the financial risk and agrees to offer some competitors' products.17

Managed Care and Women's Chronic Conditions

Managed care presents opportunities for improving on deficiencies in systems of care; it also raises a number of concerns for women with chronic illness or disability. For example, managed care may offer better integration of care, but it may restrict access to specialists and services. Coordination by a primary care physician may enhance outcomes, but for those with chronic conditions, is a generalist or a specialist better suited to serve in this role?

Disease management programs may improve women's health care under managed care. They could provide the focal point for "much-needed integration of multidisciplinary expertise and stimulate the development of innovative approaches to complex clinical problems."5 Examples of conditions for which the development of multidisciplinary guidelines for primary care implementation could be effective for womenıs health include chronic pelvic pain, type II diabetes, chronic headaches, chronic rheumatologic conditions (such as osteoarthritis, rheumatoid arthritis, and fibromyalgia), and obesity. Approaches that integrate medicine, surgery, psychology, and services such as physical therapy and nutrition may prove more effective than traditional care. There is also evidence that psychoeducational groups for women with chronic conditions lead to better health outcomes, again emphasizing the importance of including non-medical interventions in chronic disease management. Thus far, however, disease-management efforts have focused on acute conditions that affect men more than women.5

The role and training of women's primary care providers has been much discussed. For women with chronic conditions, the issues are more complex than whether an internist, family physician, or obstetrician-gynecologist is best suited to serve as a primary provider. Because women with a chronic disease may need to see a specialist more often than they would a generalist, there is some push to allow specialists to be designated the primary provider for these women. This would allow more unrestricted visits and ongoing contact with the physician the woman most needs to see. It does raise some concern, however, about how other aspects of that womanıs health will be managed. MCOs are sometimes reluctant to designate specialists as primary providers for this reason; as a result, many internal medicine subspecialists are now seeking recertification in general internal medicine to qualify as primary care providers.19

Women with physical disabilities face challenges ranging from difficulty in receiving routine preventive services due to physical limitations to needs for multiple complex and interrelated services. For example, women with physical disabilities such as quadriplegia will likely require extra time and assistance for a gynecologic examination and Pap test. It is important that women have access to providers who understand and can accommodate these particular needs, and this may be less certain in MCOs with limited networks. Restrictive networks may also limit the opportunities of women with disabilities to see specialists with knowledge of particular treatments, including rehabilitation medicine and assistive devices.20

Some MCOs have implemented programs to manage conditions of particular concern to women. Rush Prudential Health Plans in Chicago developed and pilot tested an intervention to more proactively manage the care of female enrollees over 50 with cardiovascular disease. The project consisted of a baseline needs assessment, integration of the delivery of needed services through an interdisciplinary team, referral of high-risk patients to specialized programs, conducting monthly monitoring, and testing patient compliance with the new program.21 Health Net in California has instituted a program to manage depression, involving primary care physicians in diagnosis, and an early detection program for breast cancer.13

Improved understanding of risk factors and prevention strategies for osteoporosis have led to the creation of disease management programs for osteoporosis. In the past, care for those with osteoporosis consisted of trying to prevent falls and treating fractures when they occurred. Prevention efforts instead focus on exercise, calcium intake, and a generally healthy lifestyle. Screening tools that ask about risk factors for osteoporosis can identify those in need of further evaluation through bone densitometry or urinalysis. MCOs such as Group Health Cooperative of Puget Sound, Kaiser Permanente, Sierra Health Services (Las Vegas), and AvMed (Miami) have been working to put into place osteoporosis treatment programs that involve screening, densitometry, and HRT.22

Quality Measurement

Measuring the quality of care delivered in managed care plans is challenging for many reasons, including the lack of clear consensus on what constitutes "quality" and how to measure it, the difficulty of gathering the data needed for measurement, and the difficulty of assessing outcomes, as opposed to processes, of care. The Health Plan Employer Data and Information Set (HEDIS), an iterative set of managed care performance measures administered by the National Committee for Quality Assurance (NCQA), is currently the dominant set of standardized tools for assessing health plan quality. HEDIS plays a significant role in driving the priorities of health plans in program development and resource allocation. Now in its third version, HEDIS is divided into several domains, including effectiveness of care, access to and availability of care, satisfaction, health plan stability, use of services, cost of care, informed health care choices, and descriptive information. HEDIS 3.0 contains "reporting set" measures that are to be implemented, and "testing set" measures for which feasibility and measurement specifications have yet to be worked out.

Of the 71 reporting set measures in HEDIS 3.0, only a few relate to chronic illness. The effectiveness of care domain contains three: the number of plan members receiving a prescription for beta blockers following a heart attack, the percentage of diabetic plan members who received an eye exam, and a survey of seniors to report on whether their functional ability has improved or worsened over time. Several other chronic illness measures are being evaluated in the testing set, most of them in the effectiveness of care domain. They include the number of plan members instructed to take aspirin following a heart attack, the use of appropriate medication for people with asthma, monitoring of diabetes patients through glycohemoglobin tests, prevention of stroke in people with atrial fibrillation, outpatient care through ace inhibitors for patients hospitalized for heart failure, cholesterol management of patients hospitalized for coronary artery disease, control of high blood pressure, assessment of how breast cancer therapy affects patients' functional ability, and the prescription of antibiotics for the prevention of HIV-related pneumonia. In addition, in the domain of informed health care choices, the testing set of HEDIS 3.0 contains a measure for counseling women about the benefits and risks of postmenopausal HRT. The Measurement Advisory Panel for women's health that assists NCQA in suggesting and refining measures for HEDIS broadened this measure during the pilot phase and renamed it "counseling patients on options for management of menopausal hormonal changes" to assess counseling on options other than HRT.

Reasons for delaying the implementation of these measures include lack of consensus over best practice, the need for valid risk adjustors, and methodologic issues. For example, the appropriateness of medications for asthmatics depends on the level of the disease's severity, necessitating the development of a way to distinguish among levels of severity when designing measures. And there is no sound methodology for distinguishing between insulin-dependent and non-insulin-dependent diabetics for the measure of appropriate glucose monitoring, or for identifying women close enough to menopause to warrant counseling on hormonal changes.

Part of the difficulty in designing quality measures for chronic illness is that by definition the management of diseases over time does not constitute a discrete episode of care. The HEDIS domain called health plan descriptive information contains information about plan's structure, rules, staffing, and management, including how the plan oversees its providers and its policies on how services are provided. The current 3.0 reporting set asks for information about case management programs, which essentially covers any programs for managing catastrophic, acute, or complex illness or injury. Although technically case management and disease management are not synonymous, this would be where MCOs would describe services for enrollees with chronic illness.

Future Trends and Remaining Issues

Advances in information technology hold considerable promise for enhancing disease management capabilities, beginning with electronic longitudinal patient medical records and on-line educational services for patients. Continuous updates in optimal treatment guidelines will also drive improvements in care. Interventions should increasingly focus on patients' psychosocial needs and not just clinical morbidity, as significant comorbidity exists between mental and physical disorders and care-seeking behavior is not often driven solely by the burden of physical illness.

Disease management programs will probably need to be customized for the Medicaid and Medicare populations, incorporating, for example, a greater emphasis on outreach. Population health management in general will require the use of both disease-specific measures of functional status and general measures of health status. Evolution towards better coordination of care for patients with multiple chronic conditions, as opposed to concentrated efforts on single diseases, is an important goal.17

As managed care systems increasingly face caring for women with chronic illness and disability, several issues will need to be addressed:

  • What is the best way to harness managed care's emphasis on primary care and its systems orientation to produce management programs for chronic illness that integrate primary and specialty care? Are generalist or specialist physicians better suited to be primary care providers for women with chronic conditions?
  • Since the financial return on investment in innovative chronic disease management programs is less immediate than that for acute care, how can MCOs operating in competitive environments be encouraged to invest in such programs?
  • How can chronic disease management programs be designed with sufficiently specialized focus while recognizing the importance of comorbidities in progression and outcomes? Specifically, how are MCOs managing women, particularly older women, who have more than one chronic condition?
  • Given the traditionally fragmented nature of women's primary care, how can MCOs design management programs for chronic illness that provide effective treatment and followup without neglecting women's other health care needs?
  • How are MCOs incorporating home care and social services into disease management programs for older women living alone or those with considerable functional disability?
  • As the managed care market is increasingly dominated by more loosely organized plans, how can these plans provide effective and integrated management programs for chronic illness and disability?
  • Do the guidelines used in disease management programs incorporate gender differences in etiology and treatment for conditions that affect both women and men?
  • Do the structural features of managed care plans - defined provider networks, restrictive drug formularies, etc. - impede needed flexibility in treating complex chronic conditions?


1. Sandy LW and Gibson R. Managed care and chronic care: challenges and opportunities. Managed Care Q 4:2;1996.

2. Freudenheim E. Healthspeak: A Complete Dictionary of America's Health Care System. New York: Facts on File, 1996.

3. Lohr KN et al. Chronic disease in a general adult population: findings from the RAND health insurance experiment. West J Med 145:4;1986.

4. Fox PD and Fama T. Managed care and chronic illness: an overview. Managed Care Q 4:2;1996; Sandy LW and Gibson R. Managed care and chronic care: challenges and opportunities. Managed Care Q 4:2;1996.

5. Carlson KJ. Primary care for women under managed care: clinical issues. Wom Health Issues 7:6;1997.

6. Horton JA, ed. The Women's Health Data Book - A Profile of Women's Health in the United States. Washington DC: Jacobs Institute of Women's Health, 1995.

7. Presentation by Deborah R. Kelch, "Women's Health and Managed Care: Policy Perspectives" seminar, October 9, 1997, Sacramento, California, sponsored by the Jacobs Institute of Women's Health and the Pacific Institute for Women's Health.

8. Presentation by Heidi Solz, MD, "Women's Health and Disease Management" conference, September 30-October 2, 1996, Atlanta, Georgia.

9. Presentation by Denise Faustman, MD, PhD, "Women's Health and Disease Management" conference, September 30-October 2, 1996, Atlanta, Georgia.

10. See Insights #5 (December 1997).

11. Fox PD and Fama T. Managed care and chronic illness: an overview. Managed Care Q 4:2;1996.

12. Fishman P et al. Chronic care costs in managed care. Health Aff 16:3;1997.

13. Disease Mgmt News 1:23;1996.

14. Fama T, Fox PD, and White LA. Do HMOs care for the chronically ill? Health Aff 14:1;1995; Taylor AK, Beauregard KM, and Vistnes JP. Who belongs to HMOs: a comparison of fee-for-service versus HMO enrollees. Med Care Res Rev 52:3;1995.

15. Modern Healthcare, March 16, 1998.

16. Ware JE et al. Differences in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. JAMA 276:13;1996.

17. Plocher DW. Disease management. In The Managed Health Care Handbook (3rd ed.). Peter R. Kongstvedt, ed. Gaithersburg, MD: Aspen Publishers, 1996.

18. Guralnik JM. Assessing the impact of comorbidity in the older population. Ann Epidem 6:5;1996.

19. Terry K. Here comes more competition - not-so-busy specialists are becoming generalists, too. Med Econ July 15, 1996.

20. Lamp S and Pfrommer MC. We've come a long way, but can we survive managed care? Resourceful Woman 5:3;1996.

21. Robert Wood Johnson Foundation, "Chronic Care Initiatives in HMOs," Project Summaries (

22. O'Connor K. Exposing the silent thief. Healthplan 1997 (March/April).