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The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar...

A review of studies of managed medical care demonstration programs for high-risk populations shows that, though there have been many such programs, they appear to have limited effects. Programs have often been characterized by conceptual inconsistency, about the nature of managed care, and limited goals, related mostly to cost savings. Program evaluations have often been methodologically weak. Insofar as the managed care programs have affected costs, medical care utilization patterns, or quality, the effects have been limited to subsets of the high-risk populations studied. Though managed care programs may have the same kinds of benefits for high-risk populations as they do for general working populations, they also entail substantial risk. Inferences from general to high-risk populations should be made cautiously and demonstration programs should be implemented only with careful attention to ethical, legal, and medical concerns.