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Health Services Research and the Changing Health Care System

The paper that follows, Health Services Research and the Changing Health Care System, raises some of the key questions on access and quality that need to be answered to understand what works well and under what circumstances in the midst of a rapid, market-driven transformation of the nation's health care system.

Managed Care: a fact of life for many Americans.
  • About 7 in 10 workers in firms with more than 200 employees are now in managed care plans.
  • One-third of Medicaid beneficiaries are enrolled in managed care plans, a number which has more than doubled in the last two years.
  • One in eleven Medicare patients has joined an HMO, and the Congressional Budget Office estimates this will increase to one in five under proposed legislation.
  • The growth of managed care also has important implications for uninsured patients, through its impact on institutions that serve the poor and the elimination of cross-subsidies that now support care for the uninsured.

While Congress and the President have yet to agree on how to reshape the nation's public health insurance programs, health care as we know it is undergoing rapid and radical change. The quest to slow the rate of health care cost increases has led to an unprecedented growth in managed care organizations that is transforming the entire health care system.

Our ability to monitor and assess the impact of this experiment on patient's access to care and the quality of care lags well behind market-driven restructuring. Today's health care sector is moving away from a largely non-profit industry to one dominated by for-profit systems of managed care, with capitation contracting emerging as a major new trend. Paying physicians and hospitals a fixed amount per person for each managed care enrollee encourages underutilization of services, rather than overutilization. Yet nearly all of our research has focused on identifying and measuring inappropriate and unnecessary care, not failure to receive needed care.

To a great extent, we are in the midst of a national experiment of unprecedented proportions. Monitoring is essential to assess how this is affecting access and quality of care for the insured and uninsured, on those most vulnerable, including poor families, the frail elderly, and the chronically ill. And results must be made public, if policymakers, the professional community, and the public are to be truly well informed.

The full report is not available at this time.

Publication Details



Health Services Research and the Changing Health Care System, Karen Davis and Cathy Schoen, The Commonwealth Fund, March 1996