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Boston's Community Medical Group and the Community Medical Alliance Health Plan: a national model of consumer-oriented, prepaid, managed care for independently-living persons with spinal cord injuries (SCI).

Boston's Community Medical Group (BCMG) was among the first primary care group practices to provide community-based continuous primary care to people with major disabling conditions; the first to rely upon nurse practitioners as primary caregivers, and one of the first to provide care on a prepaid capitated basis. With more than a thousand person-years' experience, BCMG has demonstrated that it is ethically and operationally feasible to 1) provide prepaid managed care to people with major disabling conditions; 2) share financial risk for that care with providers; 3) reinforce principles of independent living and consumer autonomy; and 4) assure high-quality clinical outcomes at reasonable costs.

The New Yorker cartoon (April 1, 1996) reproduced on the following page highlights a very serious contemporary concern: that prepaid managed care plans, like the hapless Humpty's HMO, ration resources, respond to consumer need only slowly and reluctantly, and, even then provide only a fraction of the services that consumers legitimately need. There are particular concerns about the effects of managed care upon people with major disabling conditions, including but not limited to spinal cord injuries (SCI). A person interviewed for a recent New York Times article (1996, January 15) on the effects of managed care upon people with AIDS said that his HMO--Health Insurance Plan (HIP) of New York--"came to seem less his ally than his enemy" (p. 1). Consumers, advocates, and healthcare professionals have made substantially the same argument about managed care and SCI. Indeed, many have argued that prepayment--and managed care more generally--is fundamentally incompatible with disabled persons' independence, autonomy, and highly complicated healthcare needs.

Boston's Community Medical Group's experience suggests otherwise; that whatever the problems of individual prepaid managed care programs, there is no fundamental incompatibility between prepayment and the social and healthcare needs of people with major disabling conditions. Throughout its 13-year history, including 5 years' experience providing care on a prepaid basis, BCMG has maintained a consistent commitment to principles of consumer autonomy and independence, provider flexibility, and high-quality cost-effective healthcare.

In the current climate of growing interest in developing prepaid managed care programs for people with major disabilities and growing concerns about such programs' social, emotional, and medical costs, BCMG's goal is to become a model for cost-effective, socially responsible, consumer-oriented primary care.

Background: Managed Care and Disability

Historically, HMO's and other managed care providers have served employee groups and, more recently, the younger and relatively healthier Aid to Families with Dependent Children (AFDC) component of state Medicaid populations. They have had little interest and only limited experience with people with SCI or other major chronic disabling conditions, most of whom have received healthcare from public or private fee-for-service programs. Even insofar as HMO's have had experience with Medicare beneficiaries, analyses suggest that they have served healthier, more independent older adults, rather than nursing home residents, people with disabilities, or people with end-stage renal disease.

More recently, with growing concerns about the costs of medical care, and especially the costs borne by public programs (most notably, Medicaid, Medicare, and the Veterans Administration), there is considerable interest in managed care programs as means of better organizing services and controlling costs. There is particular interest in managed care for people with SCI and other similar disabling conditions, because they require an extraordinary intensity of health services, because they rely heavily upon public payments, and because they account for a disproportionate share of health and social service costs.

Ethical Concerns about Prepayment

In response to this interest, there have been corresponding ethical and operational concerns about the appropriateness of managed care programs for high risk groups. As the author of the recent New York Times article noted: "Switching to a managed care network is wrenching for any patient, since it often requires a change of doctors. But it is particularly difficult for the chronically ill, since they have often developed close relationships with a collection of doctors, after trial and error" (p. 12).

There are particular concerns about managed care programs that entail provider financial risk: i.e., partial or complete fiscal responsibility for beneficiaries' healthcare costs if these costs exceed an established limit. Financial risk, critics argue, provides incentives to withhold or curtail services in the interest of profit. Managed care, they assert, can provide a rationale for providing fewer services to those who need more. Faced with threats and claims that imply that managed care means denial of service, some disabled consumers--including those with SCI--and their advocates argue that managed care programs cannot serve people with major disabling conditions, that such people have such great needs and such intimate familiarity with their own social and medical conditions they must therefore be free to make their own medical decisions, without managerial assistance, free of financial constraints.


In defense of risk assumption and prepayment, managed care advocates cite the historic struggle of people with disabilities confronting persistent barriers that prevent them from finding reliable, knowledgeable, and sensitive fee-for-service care: such impediments include architectural and transportation barriers, limited access to medical specialists, limited time with providers, and regulatory and fiscal restrictions on the development of flexible, responsive services. And, they argue that only prepayment provides the kinds of financial incentives and operational flexibility to respond quickly and appropriately to beneficiaries' complicated and rapidly changing medical, social, and psychological needs.

Managed care providers can assure prompt and predictable access to medical specialists and to mental health, counseling, and other services to treat or prevent alcohol or other substance abuse. In contrast to fee-for-service providers, most of whom have strict regulatory limits on the kinds of services that they can offer and the speed with which the services can be delivered, providers in prepaid risk-based programs have extraordinary latitude. For example, they can employ nurse practitioners, physician's assistants, and other nonphysician providers; provide home care services to people who have difficulty reaching offices; pay reasonable rates for medical specialists, skilled nursing facilities, or home providers to reflect the fact that disabled persons may require more time or greater intensity of services. They can develop self-help or family assistance programs, provide or arrange special transportation services, or selectively and expeditiously purchase or rent equipment for their patients' short- or longer-term needs. They can do these things, they say, mainly because they can reduce the use of hospital-based services--both inpatient and outpatient--and allocate the funds saved from deferred hospital admissions or reduced hospital stays to other, more appropriate needs.

In summary, in return for the assumption of at least some degree of financial risk, providers of prepaid managed care have substantially greater flexibility than their counterparts whose practices are governed by Medicaid regulations and private health insurance contracts. They argue that such flexibility is especially important for people with major disabling conditions: people who are vulnerable to a wide range of highly prevalent, morbid, or lethal secondary complications, such as decubitus ulcers, autonomic dysreflexia, and respiratory and urinary tract infections (RTI's and UTI's), that require prompt, decisive, and creative provider response.

Boston's Community Medical Group: Prepaid Managed Care for People with Major Disabling Conditions

The program which later was to become BCMG was established in 1982 as the Independent Living-Primary Care Program, a component of the Urban Medical Group (UMG). UMG, in turn, had been established in 1978 by a group of Boston area physicians, nurse practitioners, and physician's assistants--"a rag-tag band," according to a close professional friend and observer--to provide responsive, continuous primary care to Boston's inner city nursing home residents and frail homebound older adults, "people that the rest of the profession didn't seem to care about." To these ends, and despite considerable financial and professional disincentives, UMG stressed the need to provide care in home and community settings, including nursing homes, rather than inpatient settings, hospital outpatient clinics, and emergency rooms.

This unique care program was a cooperative venture among UMG, Boston's Beth Israel Hospital, and the Boston Center for Independent Living to apply these same principles and to provide these same benefits to younger adults living independently in inner city settings with such major disabling conditions as SCI, cerebral palsy, head injury, and both stable and degenerative neurologic disease. Speaking of the IL-PCP's founder and motivator--the late Dr. Marie Feltin(1)--a colleague notes that "she didn't really fit into the structured world . . . she liked to be able . . . to see people in their homes." Home visits, according to Dr. Feltin, allowed more time for questions. Another colleague said that she and other BCMG clinicians understood "the limits of medicine" and the value of "sitting and talking." Making a home visit, Dr. Feltin said, means that "you're on the patient's turf," subject to his or her schedule, and exquisitely sensitive to his or her circumstances and needs. Though "this makes some physicians feel insecure," it helped her, her professional colleagues, and, most significantly, their patients, to develop an effective trusting relationship. According to a professional colleague--a nurse practitioner--BCMG staff visits "never really felt like it was the doctor coming to see patients. It was Marie coming to see her friends."

The program's goal was to meet the healthcare needs of adults with severe disabling conditions in ways that would support their independence and autonomy and empower them to be active participants rather than passive recipients of care: that emphasized their "capacities, above all, even if they were handicapped." Typically, people living independently with SCI would use emergency rooms for the evaluation of such acute problems as fever, urinary tract infections, and respiratory infections. Often, they would lie for hours on stretchers or gurneys awaiting treatment, and would subsequently be referred to specialty clinics for followup care. They were skeptical of the traditional medical model that encouraged dependency and often failed to respect their choices. Frustrated by a system of care that relied heavily on hospital-based services, specialty care, and emergency rooms that offered little in the way of coordination or consistency of care, they wanted primary care that would provide them with accessible, continuous, personalized, responsive, and respectful care. And the IL-PCP met their needs.

One long-time BCMG consumer said that, in contrast to previous physicians, who had intimidated and mystified her, Dr. Feltin was "just normal." Another, with a high-level SCI, added that she and her colleagues were "not part of that structure, that medical construct that always treated me like an object . . . ." He continued by observing that for people with major disabling conditions, illness is bad enough, but "going to the doctor just becomes a nightmare." In this context, he said, there was considerable reassurance "knowing that they (i.e., doctors and nurses) are going to come to your home, and that it's OK. . . that it's not a problem. . . that you're sick."

BCMG Becomes Independent of the University Medical Center

In 1988, Dr. Feltin and Mary Glover established Boston's Community Medical Group (BCMG), a separate and autonomous program with an exclusive focus upon the care of people with severe physical disabilities. They moved the program's operations to the Boston University Medical Center to cultivate a growing collaboration with the Department of Rehabilitation Medicine and the New England Regional SCI Center. The program has grown by voluntary enrollment to 179 members.

Program Operations

Every consumer enrolled in BCMG has a primary physician who provides medical management and coordination and who is available to both nurse practitioners and consumers for advice and consultation, 24 hours a day, 7 days a week. At weekly team conferences, the clinicians discuss cases involving active problems or those scheduled for periodic review. The primary physician is the admitting physician of record; he or she coordinates all inpatient care.

In outpatient settings, nurse practitioners have central roles in both direct patient care and case management. Each nurse practitioner follows 40-50 patients, usually clustered geographically. For each consumer, she performs a comprehensive initial assessment; she is the first to respond to new problems. Home visits are made frequently to monitor chronic conditions and to provide urgent care in the home rather than in the office or emergency room.

As the case manager, the nurse practitioner coordinates all needed services, such as mental health, home health, rehabilitation therapies, and social services. The nurse practitioner also works collaboratively with the physician and hospital staff to coordinate discharge planning. The nurse practitioner supplements home visits with frequent phone contact to answer questions and offer reassurance, guidance, and support.

The case management function is essential to the role of the nurse practitioner in that it allows for the integration of clinical decision making and the management of resources. Once a problem has been identified, the nurse practitioner can immediately discuss the treatment options with the patient and arrange for their implementation. In the capitation model, the nurse practitioner is empowered to mobilize resources such as home infusion, home health, private duty nursing, and home respiratory care. The nurse practitioner can assess and treat more quickly than a less knowledgeable or less empowered case manager.

A recent example illustrates the range and flexibility of BCMG nurse practitioners' roles. John, a 36-year-old man with C5-6 quadriplegia as the result of a spinal cord injury sustained 20 years ago, recently developed symptoms of a urinary tract infection; he immediately called BCMG's 24-hour call service. His physician recommended an emergency room evaluation, because John sounded quite ill and because it was 5 a.m.

John refused and requested a home visit by his nurse practitioner that morning. The nurse practitioner made a thorough assessment and discussed the various treatment options with John. He continued to oppose hospitalization and requested treatment at home. Based on her medical assessment, her close personal relationship with John, her knowledge of his capabilities and support system, and her ability to mobilize appropriate medical therapies, the nurse practitioner agreed. She drew blood, obtained a urine culture and blood cultures, and initiated oral antibiotic coverage immediately. After obtaining preliminary lab data and consulting with the primary physician, she made a referral for home infusion and ordered intravenous antibiotics and fluids.

John was assessed daily and responded well to treatment. This illness easily could have resulted in a 5- to 7-day hospital stay without this coordinated approach to care.

Ultimately, it is the trust that develops between provider and patient that is the key element to this successful partnership. The home visits enhance communication and a relationship of equality which contributes to a more effective and empowering treatment of the patient.


Despite the enthusiasm of both consumers and providers for the model, it quickly became evident that traditional reimbursement mechanisms were inadequate because these placed little value on home visits, provided correspondingly low reimbursement for home visits, and offered neither recognition of nor reimbursement for the nurse practitioners' expended role. In fact, nurse practitioners initially were reimbursed through independent living centers as "skills trainers."

Beginning in 1982, a special arrangement was negotiated with Massachusetts Medicaid to reimburse the UMG at its cost on a fee-for-service basis for nurse practitioner, physician, and physical therapy home and office visits. The unique system emphasized a nurse practitioner/physician team approach, home-based services, 24-hour availability, and direct, private admission to the Beth Israel Hospital: all on a fee-for-service basis.

BCMG's fee-for-service arrangement with the Massachusetts Medicaid program continued until April 1992, when Community Medical Alliance (CMA), an independent organization with close historic and operational ties to BCMG, entered a prepaid capitated contract with Massachusetts Medicaid.

Under the terms of this arrangement, the Massachusetts Medicaid program pays monthly capitations to CMA, which, in turn, contracts with BCMG to provide a comprehensive package of services to people who meet clinical criteria described in Table 1. For those who meet these criteria, enrollment is voluntary.
Table 1

 CMA Eligibility Criteria

Spinal Cord Injury
with functional quadriplegia, quadriparesis, or triparesis.

Traumatic Brain Injury
with functional quadriplegia, quadriparesis, or triparesis

Spinal Cord Injury
with functional paraplegia, AND secondary complications including
recurrent urosepsis, OR recurrent bacterial pneumonia, OR persistent
decubitus ulcer, OR Substance abuse.

Degenerative Neurologic Illness
with functional quadriplegia, quadriparesis, or triparesis

Cerebral Palsy
with severe spasticity OR functional quadriplegia

Other Neurologic Condition
with functional quadriplegia, quadriparesis, or triparesis

Any Other Condition
requiring a minimum of 10 hours per week of personal assistance
service for activities of daily living (ADL's) OR a minimum of 14
hours per week of personal service to meet ADL and instrumental ADL

With this capitation, CMA, through BCMG, agrees to provide a comprehensive set of services described in Table 2. These benefits represent all Massachusetts Medicaid benefits, except oral pharmacy, dental care, eye glasses, nonemergency transportation, and personal care attendant (PCA; also known as Personal Attendant [PA]) services, for which Massachusetts Medicaid continues to pay on a fee-for-service basis.
Table 2

 CMA Benefits

 * Primary care
 * Medical specialty care
 * Acute hospital in patient and
 outpatient services
 * Emergency services
 * Home healthcare
 * Private duty nursing
 * Durable medical equipment
 * Home infusion therapy
 * Mental health
 * Substance abuse treatment
 * Chronic hospital
 * Adult day health
 * Adult foster care
 * Laboratory and x-ray
 * Case management

For enrollees with physical disabilities, most of whom had been BCMG's fee-for-service patients before 1992, the monthly medical service capitation was $1,997 for those who were eligible for Medicaid only. For those dually entitled to Medicare and Medicaid, the monthly capitation between 1992 and 1995 was $432. In 1995, the monthly capitation for those eligible for Medicaid only dropped to $1,680, while that for those dually entitled rose to $772.(2)

Effective April 1995, on the basis of a National Committee for Quality Assurance survey, the Massachusetts Medicaid Program authorized enrollment in CMA (and its affiliated clinical programs, including BCMG) by any person with a disability who receives Social Security Insurance (SSI). To this end, CMA receives a monthly capitation, currently under negotiation, of approximately $446.07, for a range of services that is as comprehensive as those provided to those with severe disability and AIDS. Once approved, this contract will allow BCMG to offer prepaid managed care to virtually all Massachusetts Medicaid beneficiaries with SCI, not just those who meet the highly restrictive eligibility criteria in Table 1.

Current Status and Projections for Growth

Since its inception, BCMG, through CMA, has provided care to 254 people;

and in January 1997, the prepaid caseload is anticipated to be 205 individuals with major disabling conditions, of whom 35 percent are female and 20 percent are members of minority groups. Some 55 percent fall within the 15-39 age range; 10 percent are 60 or older. Forty-two per cent of BCMG clients have stable neurologic disabling conditions, most notably, cerebral palsy; 28 percent, cervical-level SCI; 11 percent, degenerative neurologic conditions; 7 percent, traumatic brain injury; and 9 percent, paraplegia with the complications noted. More than three-quarters receive the services of one or more personal care assistants.

To meet their needs, BCMG employs 1.3 full-time equivalent physicians, 4.0 full-time equivalent clinical nurse practitioners, 0.4 full-time equivalent administrative nurse practitioner, and 4 full-time equivalent administrative and clerical staff.

Use of Services

Figure 1, which is based upon 372 person-years experience--between April 1, 1992 and March 31, 1994--shows the per capita monthly expenditures and proportion of total expenditures for each of 9 categories of healthcare. There are several remarkable features:

* The proportion of expenditures for inpatient services is relatively small, less than a quarter of all expenditures. The corresponding figure for Massachusetts Medicaid beneficiaries with major disabling conditions who receive care on a fee-for-service basis is 55 percent.

* The proportions for durable medical equipment (DME) and supplies, in contrast, is quite high, higher than inpatient services. The evaluation and development of the DME program has been one of CMA's greatest challenges. Consumers have developed strong loyalties and highly personalized relationships with vendors over the years. Often, they are extremely reluctant to change providers, even if CMA or BCMG feel that other providers can provide equal or greater value at lower cost.


Access to appropriate equipment and supplies and to prompt, efficient, and reliable wheelchair repairs is integral to independent living. BCMG has hired a DME coordinator to organize services by acting as a liaison between enrollees, vendors, and clinicians to assure prompt delivery of services while avoiding duplication. Based on a survey of enrollees, preferred vendors are being approached for contracting that will include specific service expectations as well as negotiated fees and volume discounts. All requests for wheelchairs must be evaluated by a physical therapist in the seating clinic. Costs are expected to rise despite these efforts, however, with the explosion of technology currently available in the form of environmental control units and computer assistive technology.

* The proportion of expenditures for medical specialist services also is relatively small; the ratio of primary care to specialist services is more than 5:1, and Table 3 shows that nurse practitioners rather than physicians are the main providers of primary care services; the ratio of nurse practitioner to primary physician expenditures is more than 2:1. BCMG patients experience about 1.2 primary care visits per member per month (PMPM), about 15 visits annually. Of these, 87 percent are home visits and 89 percent are provided by nurse practitioners.
Table 3

 BCMG Visits: January 1994-January 1995

Visit Type Total Percent PMPM
MD 285 11 0.13
NP 2,372 89 1.08
Office 358 13 0.16
Home 2,299 87 1.05
Total 2,657 100 1.21

The mental health and substance abuse benefit has no limits; yet, the service utilization is quite small. The thought, which is currently under review, is that much of the needed supportive counseling and crisis management is provided directly by the primary care team during day-to-day interactions, reducing the need for more formalized mental health services.

In summary, BCMG's experience defies a number of prevailing prejudices about continuing care for people with major disabling conditions. It is home- and community-based, rather than based in institutions. It relies heavily upon primary care providers rather than medical specialists. And, most notably, in contrast to conventional wisdom that characterizes nurse practitioners as "physician extenders," BCMG's nurse practitioners are truly primary caregivers, closely supported by primary care physicians (internists) with only occasional use of specialty medical care.

Despite BCMG's progress to date with expanding opportunities for people with disabling conditions to participate in comprehensive, coordinated, consumer-oriented primary care, there remain several areas of unmet need.

BCMG's providers have refocused dollars from specialty and hospital-based services to a more personalized, individualized approach, without apparent compromise of quality of care. What are the boundaries for using medical dollars to assist people with disabilities in gaining access to interventions that would maximize function and support healthy life styles? Such services as computer-assisted communication devices, recreational programs, and access to fitness centers could provide tremendous enhancements of both social and medical well-being. So could such services as additional physical therapy or acupuncture to relieve spasms and pain. However, such services traditionally have not been considered medically necessary. Determining the limits of medical benefits and identifying funding sources to provide them are major challenges for CMA and BCMG.

Preliminary Studies of BCMG's Impact on People with SCI

An analysis of BCMG's experience with skin care and the prevention of pressure ulcers, undertaken as part of its routine quality assurance program and described in detail in a recent paper, shows that prepaid managed care may reduce the morbidity, hospital admissions, and medical care costs associated with one of the most pervasive, destructive, and costly consequences of major disabling conditions. If this finding is borne out by larger and more definitive studies, it will have special relevance for people with SCI.

How did this happen? Though the numbers are small and the experience limited, these data, supplemented by interviews with BCMG's managed care providers, suggest that the most significant difference is "clinician empowerment": i.e., the ability of a nurse practitioner or physician with primary responsibility for the care of a person with SCI or other similar major disabling condition, to order rather than request interventions. Some such interventions entailed the use of durable medical equipment: for example, cushions or mattresses. Others entailed admissions to chronic disease hospitals or skilled nursing facilities. However, whatever the interventions, once they had decided upon them, BCMG nurse practitioners and physicians were able to assure that they were applied without delay. This empowerment appears not only to reduce numbers of admissions for the management of pressure ulcers; it also appears substantially to reduce numbers of surgical procedures, average length of stay, and associated costs.

BCMG and the Refinement and Dissemination of the "Boston Model" of Prepaid Managed Care

From the program's inception, BCMG staff have recognized the importance of research for purposes of evaluation and quality improvement as well as a means of disseminating their experience to healthcare providers, consumers, and community agencies concerned about the quality and costs of healthcare. Working with researchers from the Boston University School of Public Health (BU/SPH), they have participated in special studies of such topics as hospitalization and the use of other medical care services; temporary disability; alcohol, tobacco, and cannabis use; and the effectiveness of managed medical care. There are now plans to work with BU/SPH and with Boston Medical Center's Model Spinal Cord Injury Center to refine a skin care assessment tool.

In the same context, and working with the same two organizations, there also are plans to undertake a prospective evaluation of the effects of prepaid managed medical care for people with SCI. This evaluation will be concerned with a wide variety of clinical, social, and psychologic outcomes, including, but not limited to, skin care.

More recently, BCMG staff have been active participants in efforts by BU/SPH's Medicaid Working Group, a project funded by the Pew Charitable Trusts and the Robert Wood Johnson Foundation, to help selected states develop prepaid managed care programs for Medicaid SSI beneficiaries. To this end, BCMG will continue to evaluate and improve its services in order to serve as a model for other similar programs in different locales.


Boston's Community Medical Group and the Community Medical Alliance acknowledge with gratitude financial support from the Robert Wood Johnson Foundation and the Pew Charitable Trusts.


(1.) Dr. Feltin died November 1994. The quotations that follow are taken from a testimonial film.

(2.) By way of comparison, CMA's capitations for people with AIDS are $4,486.60 and $1,554.24, for those who are and are not Medicare beneficiaries, respectively. All rates are subject to periodic review.

(3.) Forty-seven people continue to receive care on a fee-for-service basis, either because they are not eligible for Medicaid or because they do not meet the clinical criteria noted in Table 1.

For more information, please contact: Allan R. Meyers, Ph.D., Professor of Health Services, School of Public Health, Boston University School of Medicine, Boston, Massachusetts 02118. Telephone: (617) 638-4510; FAX: (617) 638-5374; internet:


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[21.] Rosenthal, E. (1996, January 15). Managed Care has trouble treating AIDS, patients say. New York Times, pp. 1 ff.

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Title Annotation:Spinal Cord Injury: Part 1 of
Author:Meyers, Allan R.
Publication:American Rehabilitation
Date:Sep 22, 1996
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