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Managed Care

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Managed care has spread from the United States to Latin America with an uncertain effect on quality and access to care

With increasing saturation of the managed care market in the United States, many managed care organizations (MCOs) are exporting their managed care product to Latin America for substantial profits. For instance, overall revenues from managed care in Brazil during 1995 were nearly $3 billion. Access to large pension funds that support health insurance systems, fewer restrictions compared with the United States, and a surplus of Latin American doctors who are willing to work for relatively low wages are just a few of the incentives. But the impact of managed care on health care access and quality in Latin America remains uncertain, concludes a study supported by the Agency for Health Care Policy and Research (HS09703) and led by Howard Waitzkin, M.D., Ph.D., and Celia Iriart, Ph.D., of the University of New Mexico, Albuquerque.

A review of articles on the exportation of managed care from 1980 through 1998, as well as interviews with top executives and a review of Web pages and annual reports of international corporations, financial institutions, and government agencies revealed that required copayments have introduced barriers to care. In Chile, each year about 24 percent of patients covered by MCOs receive services in public clinics and hospitals because they cannot afford copayments. Lengthy means-testing to qualify for free care at self-managed public hospitals of Argentina and Brazil has resulted in an average 30 to 40 percent rejection rate at some hospitals. The researchers conclude that the outlook for the people of Latin America is not necessarily favorable. The executives responsible for the exportation of managed care have emphasized its financial rewards and have rarely considered preventive care or quality control, goals that have historically been valued by some HMOs in the United States.

As noted in an accompanying editorial by Eliseo J. Perez-Stable, M.D., of the AHCPR-funded MEDTEP Research Center for Minority Populations at the University of California, San Francisco, MCOs can operate in Latin America with fewer restrictions than in the United States. Controversial practices that affect physicians' relations with MCOs in the United States—such as the use of financial incentives to limit care—are not issues in Latin America. Dr. Perez-Stable points out that the presence and continuing growth of managed care could represent a major advance for the health of the people of Latin America if it leads to the establishment of health systems that emphasize the coordination of care and the MCOs make a commitment to medical education and research. Unfortunately, concludes Dr. Perez-Stable, that is not the current situation.

See "The exportation of managed care to Latin America," by Karen Stocker, M.A., Dr. Waitzkin, and Dr. Iriart, in the April 8, 1999 New England Journal of Medicine 340(14), pp. 1131-1136; and "Managed care arrives in Latin America," by Dr. Perez-Stable, same issue, pp. 1110-1112.

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