Private Payers Serving Individuals with Disabilities and Chronic Conditions. A. Introduction


Chronic illness and associated disability are common among working Americans and their dependents. While researchers have extensively studied the impact of managed care systems on the use and cost of health services in general, they have focused little attention on the impact on chronically ill individuals. These individuals are more likely to use services, and their health care needs may differ from those of the general population due to access difficulties caused by limited physical mobility or mental functioning. Corporate leaders and policymakers need information about the health care experiences of chronically ill people to judge whether current health systems perform adequately for this group. Furthermore, they need simple, straightforward statistics to serve as benchmarks for comparison to their own disabled or chronically ill employees.

This chapter meets these needs by presenting descriptive analyses of the demographics, employment status, case mix and service use of chronically ill people with private insurance. This information serves two purposes. First, it serves as a point of comparison for corporate and public officials assessing the availability and quality of care for the chronically ill in the systems they control. Second, it frames and guides the more advanced statistical analyses presented in later chapters.

Subsequent chapters of this report examine in greater detail the issues raised here. Chapter 6 investigates the impact of health plan type on utilization and expenditures, controlling for differences among those enrolled in different types of plans. Its findings should facilitate discussions of policies designed to enhance access to high-quality health care services for chronically ill individuals.

The second and third studies are natural extensions of the first. Chapter 7 analyzes whether risk-adjustment systems for individuals with diverse chronic health problems will enable employers and health plans to predict expenditures for those with chronic illness. Chapter 8 assesses whether risk-adjustment methods for people with chronic mental illness will allow health plans to predict accurately expenditures for that population. The results of these two studies will assist public and private policymakers to improve access to all types of health plans. The results will also help health plan administrators who want to learn about better methods for assessing the financial risks of enrolling chronically ill people.

In this chapter, we provide some relevant background information on managed care for people with potentially disabling chronic illnesses. Next we describe the methods used to create the descriptive profile. Then, we present results of the descriptive analyses. We conclude by comparing our results to those of other studies and by offering suggestions for additional research.

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