Managed Care Experiences of Persons with Disabilities.

In 1993 and 1994, health policy analysts and the general public expected that health care reform would originate from Washington, D.C. By 1995, it became clear that the impetus for reform was not the government but the private marketplace (Bodenheimer & Grumbach, 1996). The United States spends more on health care costs per person and as a percentage of gross domestic production than any other country in the world. The health care industry, therefore, is in a state of dynamic change because of the explosion in spending and the ever-increasing costs in the delivery of health services (Fuchs, 1997; O'Neal, 1995; Richardson, 1992). Controlling health care costs is more than a good idea; it has become an economic necessity (Freiburg, 1993).

At the center of all these changes is the growth of managed care organizations (Freiburg, 1993; Richardson, 1992; Rodwin, 1996; Schlesinger, Gray, & Perreira, 1997). Managed care has changed the nation's health care system more significantly than any other practice since employers established a market for private health insurance during World War II (Drake, 1997), and is rapidly restructuring our system of health care delivery (Collins, Schoen, & Khoransanizadeh, 1997). In 1996, it was estimated that 100 million Americans were in managed health plans (National Committee for Quality Assurance, 1996). As approximately 20% of the population in the United States has some type of disability (Kraus, 1996), the number of people with disabilities in managed care health plans is estimated to approach 20 million.

This study addresses the questions of whether those persons with disabilities in managed care plans believe that managed care: (a) provides an adequate level of treatment of their disabling conditions, (b) results in prevention or successful treatment of secondary complications of their disabilities, and (c) adequately meets their primary health care needs.

What is Managed Care?

"Managed care" is a loose term used to identify a wide variety of ways of organizing and financing the delivery of health care services (Churchill, 1997; HealthCare Consultants of America, Inc., 1993; Lyle & Torras, 1996). It describes a system of health care cost containment that deviates from the traditional health care delivery system by using pre-arranged fee structures and utilization review procedures instead of fee-for-service billing. The aim is to reduce the price and quantity of health care services. Managed care organizations include health maintenance organizations (HMOs), preferred provider organizations (PPOs) and other managed care entities (Freiburg, 1993).

HMOs are organized health care systems that are responsible for both the financing and the delivery of a broad range of comprehensive health services to an enrolled population. HMOs are responsible for providing health care services to their covered members through affiliated providers who are reimbursed under various methods (Kongstvedt, 1993).

Patients enroll in HMOs by paying fixed monthly premiums. Patients pay nothing or relatively small amounts out-of-pocket when they need medical care (HealthCare Consultants of America, Inc., 1993). Generally, preventive care services are emphasized and covered. Some HMOs employ salaried physicians who work full-time for the HMO (a staff model HMO). Another model is the group model HMO in which the group is often paid under a capitation arrangement for specified services. A third model is the individual practice association (IPA) or network model HMO that contracts with physicians in private practice who treat the plan's patients as well as other patients (Lyle & Torras, 1996). A fourth way HMOs provide service to enrollees is to directly contract with individual providers (Freiburg, 1993).

Preferred provider organizations (PPOs) are hybrids, somewhere between an IPA model HMO and a traditional insurance plan. A group of physicians may contract with self-insured employers or insurance companies to provide care on a discounted basis. The physicians agree to utilization control measures (HealthCare Consultants of America, Inc., 1993).

Individuals with Disabilities in Managed Care Organizations (MCOs)

In the past, people with major disabilities had to depend heavily upon family and friends to meet their needs or they had to live in institutions. The establishment of independent living programs in the 1970s that provided training in independent living skills, peer counseling, information, and referral services (including attendant referral) enabled many individuals with major disabilities to live independently (Meyers et al., 1987).

Severely disabled individuals have complex medical care needs and frequent medical complications. These individuals require a variety of medical care contacts and sometimes frequent and prolonged hospitalizations (Meyers et al., 1987; Tanenbaum & Hurley, 1995). Danis and Churchill (1997) report that individuals with such conditions may have greater medical vulnerability as their illnesses may cause unpredictable events such as infection, pneumonia, and decubitus ulcers. Huntt and Growick (1997) write that managed care operates best within a predictable framework, where treatment protocols are standardized. This model may not work as well when serving people with disabilities who experience complications, secondary conditions, and frequent use of allied health services (Huntt & Growick, 1997). Haas (1997) notes that there are a growing number of patients with serious conditions and chronic illnesses that are already claiming denial of services in managed care systems. Gans, Mann, and Becker (1993) have said that individuals with disabilities often have inadequate access to primary care providers.

The potential benefits of managed care plans are the elimination of incentives for overuse of services and the reduction of financial barriers to care by cutting out-of-pocket costs. Managed care plans have the potential to coordinate services, deploy modern information systems to monitor quality, and assess the performance of the individuals in the system (Rodwin, 1996). Patients with major disabilities may also be frequent users of specialists and high-cost medical services. Therefore, they may be perceived as undesirable patients who will be a drain on the resources of a managed care system (Gans et al., 1993; Huntt & Growick, 1997).

Method

Background of Participants

Sixteen persons with disabilities were interviewed, instead of the original 15 as planned, because one participant brought a spouse, who also qualified for the study. Background material was collected on the 16 individuals interviewed. Twelve were female; 4 were male. The mean age was 45.25 years. The racial breakdown of the participants in our study was 13 white, 2 African-American, and 1 Hispanic. Seven were married. Four had children. Three had high school diplomas, 7 had some college preparation, 2 had a college degree, and 4 had postgraduate degrees. Eleven were working. Thirteen of the participants were enrolled in HMOs; 3 were in PPOs. The disabilities of the participants in the study are: (a) post-polio syndrome (5), (b) spinal cord injury (3), (c) multiple sclerosis (3), (d) lupus erythematosus (1), (e) bipolar disease (1), (f) scleroderma (1), (g) amyotrophic lateral sclerosis (ALS;1), and (h) asthma and fibromyalgia (1).

Procedure

To address the questions in the present study, the investigators designed a non- standardized questionnaire to interview 16 individuals with disabilities in managed care health networks. The questionnaire included both a list of general topics to be discussed with the interviewees and some open-ended questions to prompt the interviewees. The interviews were semi-structured and conversational.

Individuals with a variety of physical disabilities were sought. The investigators contacted several organizations in the Houston (Harris County), Texas, area that provided support services to persons with disabilities. The investigators asked these organizations to help look for individuals who were at least 18 years old, who had a disability, and who were enrolled for their health care needs in an HMO or a PPO.

Individuals that were recommended by the organizations were contacted. Interviews were set up in the investigators' office or in the interviewees' homes or places of business. The interviews lasted about one hour. The interviewees were encouraged to speak freely. The interviewer both tape-recorded and wrote interview notes during each session. One investigator conducted all the interviews. Each interview was then transcribed verbatim.

All the transcribed documents were introduced into QSR NUD*IST (Non-Numerical Unstructured Data Indexing, Searching Theory-Building), Version 3, (QSR NUD.IST) a software program designed for qualitative data analysis. In QSR NUD*IST, Version 3, a transcript is reformatted to assign a unique number to each line of text. With the assigned numbers on each line as a guide, QSR NUD*IST enables the researcher to highlight sections of text in each interview document and to place the highlighted sections of text in a node (or topic) that is created by the researcher. Text that is highlighted can be from one sentence, from several paragraphs, or from the entire document. The researcher may create sub-nodes (sub-topics) and more nodes under each sub-node. All information listed in each node can be saved and stored in an organized system. In this study, the creation of nodes was driven by what the interviewees said; therefore, the interpretive structure for each document was not provided a priori. In this method of analytic induction, categories of information are derived directly from and grounded in the data, as opposed to categorizing data in a pre-existing analytic structure (Glaser & Strauss, 1967). The major nodes or categories that developed from the interviews are listed in Table 1.

Table 1
The Major Topics in This Study

Background material on the participants

Different types of providers the participants used

Services included by the MCOs

Satisfaction level of the participants

Major practices of the MCOs, both beneficial and
problematic

Medical and nonmedical problems of the participants

Reports were generated from each category which contained text (statements by the participants) that was specifically chosen from all the transcribed interviews to be included in the node. The reports provided the investigators with a means to do a cross-case analysis. Some categories seemed particularly suited for comparison or contrast. Each category had important statements of the interviewees that could be used as quotations in the findings.

Two other devices helped in the analysis. In QSR NUD*IST, Version 3, the interviewer wrote memos under each node as the analyzing of the interview document was done. The memos contained the impressions of particular experiences the participants in the study reported. The investigators also had interview notes to draw on as the analysis was done to take another look at the context in which the participants' statements were made. The investigators did purposeful sampling of individuals with physical disabilities enrolled in MCOs and sought repetition of ideas in the collected data.

Results

Providers

The participants in the study reported using a wide variety of health care providers. Not only did the participants mention their primary care physicians and specialists to whom they were referred, but also they spoke about getting care from nurses, nurse practitioners, physician assistants and physical therapists, especially when they needed immediate attention. A participant in our study mentioned chronic bladder and kidney infections that arise quickly and said:

   You don't need to go to an emergency room and what they have is ... it is
   really hard to get in there on a real quick turn around basis and see the
   doctor ... and I go to X Clinic, my doctor is there. They have something
   called `triage' but if you go ... you're probably not going to see a
   doctor. You are going to see like a nurse or a nurse practitioner and
   things like that.

Although the implication of the participants' statements is that they could not always gain access to their physicians, when they did, almost two-thirds of our participants spoke about their positive relationship with their primary care physicians. Moreover, nine participants spoke about a specialist with whom they were pleased.

Included Services

One of the features the participants in the study reported about their managed care plans was that the HMOs and PPOs had many included services, such as supplying medications, giving a yearly medication allowance, supplying equipment, and giving the participants yearly tests that could prevent health problems. The low cost of medications was often a primary reason the participants were drawn to MCOs. One participant stated:

   Because of my hypertension, I have to take drugs for hypertension and it
   costs me about $150.00 a month to buy those drugs. In a managed care
   situation, I paid $7.00. Probably total about $14.00 to $21.00 a month for
   medicine that costs me $150.00 right now a month.

The MCOs of the participants in this study sometimes provided equipment such as braces and wheelchairs. A participant said:

   I mean, as I said I was with them [the MCO] for over 20 years and so, I
   mean I had a lot of bills and claims and all, and I never really had any
   problems. I mean they always paid for brace work that I needed done and I
   wear a back brace and they always paid for that.

Other services the interviewees reported as included in their health plans were mammograms, Pap smears, and diet information and services. Although mammograms were made available to some of the participants in this study, the participants also stated that there were difficulties in getting a mammogram.

The participants also appreciated that their managed care plans had after-hours clinics, physical therapy, and counseling services. However, the participants were not totally enthusiastic about these services because of the limitations put on these services by their MCOs. Although several participants had physical therapy services available in their managed care plans, they had to get pre-approval for a limited number of sessions. In one case the physical therapy was the wrong type of therapy for the participant's particular disability. This participant had post-polio syndrome and wanted to get hydrotherapy to improve his functioning:

   I wanted water therapy, hydrotherapy. In all my reading and all my personal
   experience this is the only appropriate exercise for a person with very
   serious physical weaknesses that I have. Yet, I was sent to a program that
   could not accommodate me. They did not have an assistance lift, a physical
   therapy pool. The therapy that was proposed was exhaustion exercise style
   therapy.

Satisfaction and Dissatisfaction Levels

After reviewing the text of the interviews in the reports generated from QSR NUD*IST, Version 3, the investigators found all the participants in the study described features in their health plans that satisfied them or dissatisfied them. Tables 2 and 3 list the categories under satisfaction and dissatisfaction found in the texts of the participants' interviews.

Table 2

Areas of Reported Participant Satisfaction with Care

Managed Care Practice                             Number of
                                           Satisfied Participants

Primary care physician                               10
Specialist physician                                  9
Good medical care                                    11
Obtaining appointments                                2
Ability to see different physicians                   1
Communication with physician                         11
Advocating for himself or herself                    10
Preventive care                                       2
Doctor close by                                       1
Table 3

Areas of Reported Participant Dissatisfaction with Care

Managed Care Practice                             Number of
                                          Dissatisfied Participants

Delays                                                3
Special needs not met including                       2
inaccessible equipment/
Proper specialist not in plan/                        7
Unable to get most effective medication               4
Physicians in general                                 2
Doctor's advice                                       5
Primary care physician                                4
Specialists                                           5
Premiums too high                                     1
Credit or financial problems                          1

The participants were often satisfied with their primary care physicians and the specialists to whom they were referred. They reported that their doctors had good diagnostic skills and a caring attitude. A participant with spinal cord injury, who was referred to a specialist for a bladder infection, appreciated that the doctor encouraged him to let his attendant give him injections of antibiotics at home. This participant could return to work more quickly because he did not have to enter the hospital for treatment.

Another result of interviewing the participants about their satisfaction and dissatisfaction levels with MCOs was that, in many instances, the participants felt that there was good communication between them and their primary care physicians, specialists, or both. One participant with a spinal cord injury said about her primary care physician:

   The first time I ever went to see her, one of the first things she told me,
   she said, "You know, I really don't know anything or I know very little
   about spinal cord injury. So you are going to have to really help me here."
   So, one part of that I liked because at least she was willing to listen to
   me.

Many participants in the present study said that they had to be advocates for their health care needs. They tried to be well informed about their disabilities and the care that they needed. Many participants had to be, in order to reach a certain level of satisfaction with their managed care plans. One participant with multiple sclerosis stated:

   I am a very outspoken ... So, I don't have any problems because I speak up
   and by the time I go to see a doctor, too, I have read up on what it could
   be or what and asked these questions.

One of the participants with a spinal cord injury needed to have more bladder surgery. The urologists in the participant's plan did not feel comfortable doing the procedure on this individual. The participant had to be persistent in advocating that a urologist outside the plan perform the surgery. The plan's urologist finally referred the participant to a urologist outside the plan. The participant had to wait 6 to 7 months to get the surgery done. She said, "I had to fight and not take no for an answer."

The participants expressed dissatisfaction with their managed care plans in several respects. Thirteen felt their special needs were not being met. These unmet special needs included inaccessible equipment, not finding the proper specialist in their plans to handle their disabilities, and not getting the most effective medications for their chronic conditions. One participant with scleroderma said that her primary care physician could make referrals only to physicians in the plan. The participant could not be referred to an excellent rheumatologist, outside the plan, that she had been seeing for 10 years and who was familiar with scleroderma.

Another unmet special need of four participants in this study was trying to get the most effective medications for medical problems related to their disabilities. One of the participants with lupus erythematosus said that her doctor could only prescribe a generic anti-inflammatory medication to relieve some of her symptoms. Another more effective medication been taken for years but was not approved by the participant's MCO. The substitute medication did not provide the same degree of relief.

Besides their unmet special needs, other dissatisfactions the participants reported included one complaint about high premiums for joining their managed care plans and having credit or financial difficulties. One participant in the study with a graduate degree reported she once saw a rheumatologist who tried to get her to stop working because of her disability:

   I did see another rheumatologist and she basically believed that you should
   sit home and knit ... We had a difference in opinion if there are
   medications available that will allow me to work. She did not believe I
   should be taking them. She believed I should be home in bed.

Benefits and Problems for Persons with Disabilities in Managed Care Health Plans

The participants in this study were satisfied and dissatisfied with certain features of their managed care organizations. However, the investigators also found, from reviewing the text of the interviews, that the participants in the study encountered other beneficial and problematic practices in the MCOs. Although the participants might have expressed some satisfaction and dissatisfaction with these benefits and problems, the participants clearly had a need to specifically identify these benefits and problems as part of what they experienced in a managed care system. Tables 4 and 5 list the categories under problems and benefits that the investigators generated using the texts of the participants' interviews.

Table 4

Reported Benefits of MCOs for Persons with Disabilities

Managed Care Practice                          Number of
                                          Favorable Comments

Patient's physician belongs to MCO                 1

Small co-pay                                       4

Authorizations for treatment                       1

Medications included in plan                       3

Directory of physicians available                  2

Second opinions available                          2

Payment of medical bills                           1
Table 5

Reported Problems of MCOs for Persons with Disabilities

Managed Care Practice                    Number of Participants
                                          Reporting Problems

Delays in getting test results,                    2
making appointments,                               6
referrals to specialists,                          5
payment of services,                               3
scheduling procedures,                             2
sending explanation of benefits,                   1
and filling prescriptions                          1

Brief office visits                                4
Had to use different primary
care physicians on visits                          5

Inaccessible equipment or lack
of equipment                                       2

Denial of services including
referrals to specialists,                          9
paying for medical services,                       9
most effective medications not in plan,            3
and denial of illness                              1

Communication between primary
care physicians and specialists                   10

Communication between patients
and physicians                                     5

Primary care physician can't
treat disability                                   7

The participants reported a variety of problems with their managed care health plans. First was the problem of delay. Delays in getting appointments (6), test results (2), and referrals to specialists (5) were reported. The participants also reported delays in: (a) payments made by the MCOs for medical services (3), (b) scheduling procedures (2), and (c) getting prescriptions filled (1). One participant with post-polio syndrome, in a wheelchair, who was enrolled in an HMO, reported difficulty in getting a urinary tract infection (UTI) diagnosed by her primary care physician:

   I saw one doctor, and ... I said, "Look, I have a UTI." And she said, "How
   do you know?" And I said, "I know my body." And she did a urinalysis. And I
   said, "Let me know." And she put me on a very mild medication. And I would
   call every single week. And she refused any information, until she sent me
   a note, a form letter saying, "Yes you have a UTI, and you should be seen."

Another participant with a spinal cord injury went to her primary care physician for a Pap smear. She was referred to a specialist by her primary care physician for further diagnosis and treatment. She was not immediately treated:

   What happened is I called this other doctor to make the appointment to have
   something else done and this other doctor said, "Oh no, that's O. K. Just
   call me in six months," but when my primary care physician found out about
   it later, like in six months when I went to have another test done,
   apparently that is what was scary was the break in communication.

Nine participants reported that the managed care organizations to which they belonged denied some requested health services. These denials included referrals to specialists, payment for services rendered and, in one case, the participant's disabled status. This particular participant had a mild case of lupus. Her HMO denied that she had the disease:

   They sent me a letter that said I didn't have lupus. It was worded very
   politically. What it said was your test results do not support the presence
   of lupus ... or something like that. It really wording-wise did not say
   that, but when I talked to her [her physician], that was the intent of the
   letter.

When this participant had symptoms reappear, her primary care physician did more tests and said she did, in fact, have lupus.

Another problem reported by individuals with disabilities in managed care organizations was inaccessible equipment. The participants reported difficulties getting on examination tables because they were not adjustable. The physician's staff also was untrained to move the participants on and off the table and during the examination. Some participants reported difficulties in getting a mammogram and eye examinations that were effective. The participants could not get into the right position for the equipment to work properly. Some participants never knew their weight because platform or sitting scales were unusual in their physicians' offices.

Four of the participants also reported that they often experienced brief office visits with physicians. Office visits could be as short as five minutes. Five participants also reported that there was a high turnover of primary care physicians.

Another significant problem for individuals with disabilities enrolled in managed care health systems was that their primary care physicians had great difficulty treating their disabling condition and any related illnesses. Seven participants reported this problem. Sometimes the physicians would admit to the participants that they knew little about their disabilities, because they had no exposure to the disabilities in their medical training. One participant with scleroderma, a chronic disease that leads to progressive fibrosis of the skin and other organs, said about her primary care physician:

   She had no earthly idea about scleroderma. She did not know how scleroderma
   affected the other aspects of my health and admitted to me that I knew more
   about this disease and how it affected patients in general than what she
   knew. She tried to do a good job and she tried to provide me with the care
   that she could under the limitations of the plan.

Often the treatment by the primary care physician was described as incomplete or ineffective. Sometimes the primary care physician might consult a specialist on the telephone to get more information. This technique helped our participants.

Discussion

The literature in the area of managed care and its effects on the experiences of persons with disabilities suggests that persons with disabilities have complex medical care needs, and frequent medical complications, and are highly vulnerable medically. Navigating a managed care system, in which treatments and procedures are fairly standardized, was a difficult and challenging process for the participants. In fairness, it should be noted that some of the problems identified (i. e., brief office visits, inaccessible equipment, payment issues) may also occur with traditional service delivery systems.

There are benefits in a managed care system that create, in a quest for cost-efficiency, a total package of health care services for its enrollees. Employers, insurance companies, and consumers all have lower out-of-pocket costs in this system. Individuals with disabilities who are enrolled in managed care plans can take advantage of the many services included in the package they are offered. The participants in the study especially liked that they had low-cost medications and doctors' visits and that they sometimes received equipment or assistive devices through the plan. They also liked the availability of preventive health care tests and information. They seem to be very concerned with lower costs because they knew they would have frequent medical care contacts and they knew they would need a plentiful supply of medications.

The participants in this study implied that their health plans did not always give them the flexibility to obtain services when they needed them. Often a person with a disability experiences symptoms at unpredictable times, and in a managed care system, it is difficult to see a provider on short notice.

Policy Implications

There are policy implications that should be addressed as a result of this study. One of the major difficulties that the participants in this study discussed was that primary care physicians did not have the skills to treat their disabilities. If MCOs must maintain a system of primary care physicians who act as gatekeepers for all enrollees, the MCOs should determine which primary care physicians have the skills to treat persons with particular disabilities or which physicians would be willing to obtain continuing medical education in the disability area.

Managed care organizations may want to consider making the appropriate specialists in their plans the gatekeeper physicians for individuals with chronic disease or disabilities. Specialists could bring an existing expertise to more efficiently treat a person with a specific disability. Many specialists such as rheumatologists, neurologists, and physiatrists might be better at anticipating future problems for individuals with disabilities and at providing care that prevents rather than treats secondary complications.

Participants in the study also mentioned that brief office visits with their physicians were a difficult problem for them. Visits of 5 minutes, 10 minutes or 15 minutes with their primary care physicians or specialists were not always sufficient for the participants in the study. The participants had a feeling of being rushed; they felt that a longer time with their physicians would have been beneficial for sorting out their medical problems. They felt a need to discuss not only their primary complaint, but any effects that it might have on their disability. Because individuals with disabilities have complex medical care needs, managed care organizations should consider giving these individuals extra time during physician office visits. Physicians could make a note in the chart about the extra time required for particular patients who have disabilities.

Participants in the study encountered problems with the accessibility of their doctors' offices. They also encountered difficulties getting tests or other medical procedures done at other inaccessible sites. Two participants mentioned that they had difficulty getting on examination tables that were not adjustable or had problems getting a proper X-ray because they were in wheelchairs. Managed care organizations should make an effort to help physicians evaluate their offices for accessibility. The Americans with Disabilities Act was passed in 1990; public accommodations, including the private offices of health care providers, must be accessible to all individuals.

Another problem noted by participants was that they could not always obtain approval from the managed care organization for the most effective medications they needed to control the chronic symptoms associated with their disabilities. Although some of the participants knew that particular medications were especially good for their health, they could not get approval because the medications were not listed in the plan formulary (list of medications). Managed care organizations could consider a more flexible approval plan for those individuals with disabilities who request particular medications.

Finally, managed care organizations should consider increasing the limited services they cover for persons with disabilities with respect to assistive devices, physical and occupational therapy, and mental health counseling. Some participants in the study stated that they received such services; however, sometimes these services were not effective or were not enough to meet the participants' needs. The services were either limited in scope or the process to get approval for the services was long and arduous. Persons with disabilities may find their health improved if they have more opportunity to receive effective and timely services. In the long run, these individuals will function better and will participate in the community to a greater degree.

Limitations of the Study and Recommendations for Future Research

Although the study does not purport to be generalizable to the disability population as a whole, it does capture in-depth the experiences with managed care of persons with a variety of physical disabilities. Additional research with more participants and more variability in gender, ethnicity, and age is recommended in future studies. The categories of information developed in the study might also frame a future quantitative study such as a survey or prospective research study of managed care with a particular population.

Conclusion

Participants reported both positive and negative experiences in their relationship with MCOs, and were able to identify a number of specific concerns. These individuals have complex health care problems and managed care organizations must meet their distinctive needs. To effectively serve persons with disabilities, HMOs and PPOs and other managed care organizations should build in more flexibility in their systems. The recommendations noted in this report are not likely to significantly increase costs, yet would, in the opinion of the authors, significantly improve the quality of service and participant satisfaction with the system.

Acknowledgement

Research Grant NIH-NICHHD -- Grant No. HD07465 -- 03/04.

References

Bodenheimer, T.S., & Grumbach, K. (1996). Capitation or decapitation: Keeping your head in changing times. Journal of the American Medical Association, 276(13), 1025-1031.

Churchill, L.R. (1997). "Damaged humanity": The call for a patient-centered medical ethic in the managed care era. Theoretical Medicine, 18, 113-126.

Collins, K.S., Schoen, C.A., & Khoransanizadeh, F. (1997). Practice satisfaction and experience of women physicians in an era of managed care. Journal of the American Medical Women's Association, 52(2), 52-59.

Danis, M., & Churchill, L. (1997). The ethics of providing intensive care in managed care organizations. New Horizons, 5(1), 85-93.

Drake, D.F. (1997). Managed care: A product of market dynamics. Journal of the American Medical Association, 277(7), 560-563.

Freiburg, J.P. (1993). The ABC's of MCOs: An overview of managed care organizations. Illinois Bar Journal, 81,584-589.

Fuchs, V.R. (1997). Managed care and merger mania. Journal of the American Medical Association, 277(11), 920-921.

Gans, B.M., Mann, N.R., & Becker, B.E. (1993). Delivery of primary care to the physically challenged. Archives of Physical Medicine and Rehabilitation, 74(12 Suppl), S- 15-S- 19.

Glaser, B.G., & Strauss, A.L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine Publishing Company.

Haas, J.F. (1997). The impact of recent changes in health care insurance on medical practice. Journal of Head Trauma Rehabilitation, 12(1), 1-9.

HealthCare Consultants of America, Inc. (1993). Physicians guide to managed care: A comprehensive guide to managed competition, managed care and global budgeting. Augusta, GA: HealthCare Consultants of America, Inc.

Huntt, D.C., & Growick, B.S. (1997). Managed care for people with disabilities. Journal of Rehabilitation, 63(3), 10-14.

Kongstvedt, P.R. (1993). The managed health care handbook. (2 ed.) Gaithersburg, MD: Aspen Publishers.

Kraus, L.E. (Ed.) (1996). Chartbook on disability in the United States. Washington, DC: The Institute.

Lyle, J.R., & Torras, H.W. (1996). The managed care handbook: How to prepare your medical practice for the managed care revolution. Los Angeles, CA: Practice Management Information Corporation.

Meyers, A.R., Cupples, A., Lederman, R.I., Branch, L.G., Feltin, M., Master, R.J., Nicastro, D., Glover, M., & Kress, D. (1987). A prospective evaluation of the effect of managed care on medical care utilization among severely disabled independently living adults. Medical Care, 25(11), 10571068.

National Committee for Quality Assurance. (1996). NCQA issues first national accreditation standards for managed behavioral health organizations. Press Release, (April 10)

O'Neal, T.M. (1995). Managed care: Its impact on the delivery of health care in Texas. Texas Monthly, (July), 43-66.

QSR NUD.IST (Non Numerical Unstructured Data Indexing Searching and Theory- Building) [computer program]. (1995). Sage Publications Software 3.0. Australia: Qualitative Solutions & Research Pry. Ltd.

Richardson, M. (1992). Can managed care control costs without controlling you? Texas Medicine, 88(10), 36-44.

Rodwin, M.A. (1996). Consumer protection and managed care: The need for organized consumers. Health Affairs, 15(3), 110-123.

Schlesinger, M.J., Gray, B.H., & Perreira, K.M. (1997). Medical professionalism under managed care: The pros and cons of utilization review. Health Affairs, 16(1), 106-124.

Tanenbaum, S.J., & Hurley, R.E. (1995). Disability and the managed care frenzy: A cautionary note. Health Affairs, 14(4), 213-219.

Ellen Grabois
Baylor College of Medicine

Mary Ellen Young
University of Florida at Gainesville

Ellen Grabois, J. D., LL.M., Assistant Professor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Center for Research on Women with Disabilities, 3440 Richmond Avenue, Suite B, Houston, Texas 77046.