he organization of the Cleveland health care system has undergone swift and considerable change. Ownership and influence are being consolidated in a small number of emerging large hospital-physician networks. The future direction of the insurance market is uncertain, given the attempted sale of Ohio Blue Cross & Blue Shield and the anticipated entry of several national managed care plans. However, any effects of these dramatic organizational changes on health care access, cost and quality are not yet apparent.

Most respondents believe that the numbers of uninsured have not changed measurably during the past three to five years. Although the shift in the region’s job base from manufacturing toward service sector employment may have reduced or eliminated employer-based coverage for some workers, access to affordable health insurance for owners and employees of small businesses reportedly has increased as a result of COSE’s activities. For the insured population, most observers believe that access to services has not changed appreciably. Health plan restrictions on access to specialists are few; the supply of primary care and specialty physicians is more than ample, and waiting times for appointments are described as reasonable. Networks tend to be broad and geographically extensive.

A few concerns were cited. Respondents said the use of generalists for management of chronic illness is inappropriately encouraged. Inadequate preventive care (i.e., immunizations) persists, they noted. Finally, respondents expressed concern that nonclinical personnel are used to make decisions about authorizing specialty care.

The consensus view is that premium costs have flattened or dropped in the last five years. But while purchasers are getting better deals from plans (and plans are getting better deals from providers), mainly through discounting, it is unclear whether these savings are being passed on to consumers.

The community at large and the health care sector believe that quality of care has been and remains high. As discussed earlier, the Cleveland Health Quality Choice initiative has focused more attention on quality of care. It is unclear, however, whether quality will become a more important factor in health care purchasers’ decisions.

Significant questions remain about the shape of Cleveland’s health system, and, in particular, about the balance of power among purchasers, providers and insurers:

• Will employers start to assert themselves more as purchasers and apply more pressure on health care organizations? Will they work with health plans to increase the presence of managed care, or will they seek direct contracting arrangements with major provider organizations? Will they use information on health care quality in their purchasing decisions?

• How will the implementation of managed care in Medicare and Medicaid affect the rest of the market? Will it drive a broader conversion to managed care? Will Medicaid recipients remain with their traditional providers or will they become the focus of intense competition?

• How will the entry of national for-profit hospital and managed care organizations in this market play out? What will happen to safety net providers that traditionally have cared for the poor and uninsured? What does the future hold for Ohio Blue Cross & Blue Shield, long the dominant insurer, and how will that affect insurers, providers and consumers?

• How will the three large emerging provider systems ultimately structure themselves: through ownership, contractual affiliation or through vertical or horizontal integration? Will there be a consolidation of current provider capacity and a reduction in underlying costs? Taking a broader view, will these changes affect clinical services and patient care? Will there be true integration of services at the clinical level, as many observers envision, or will consolidation remain chiefly administrative?