ergonomics programs. Both of these experiments showed large decreases in employer or insurer expenditures, both medical payments and disability payments. Quality of care was not directly assessed in either study, but the Washington study included telephone interviews with injured workers at 6 weeks and 6 months after injury. No significant differences between the intervention and control groups were seen in reports of pain, mental health, or physical functioning at either time, but at 6 weeks the workers receiving treatment through the managed care organizations were somewhat less satisfied with their treatment overall and their access to care. The Maryland study reports only that despite freedom to opt out at any time, 99 percent of the injured workers in the managed care group chose to stay within the system. Also of note is the fact that the number of claims was actually higher in the managed care cohort, so it is unlikely that the large cost savings were simply the result of a denial of claims.

Twenty-nine states currently have some type of managed care program for workers’ compensation, costs to insurers and employers are down (Mont et al., 1999), and workers’ compensation is once more a profitable sector for insurers (National Council on Compensation Insurance, as cited by Consumer Reports, 2000). Managed care is thus very likely to be a major part of workers’ compensation for the foreseeable future.

It is difficult to say with confidence that the market-driven changes in health care delivery will continue to evolve with cost reduction as its major theme. Signs of competition on the basis of quality, as well as increasing pressure on governments to intervene with “patient bills of rights” and more specific mandates like those that prohibit “drive-through” births, suggest that the pendulum may have started to swing away from cost cutting as a prime mover. Nevertheless, there are a number of features of U.S. health care today that are likely to affect the occupational safety and health workforce, primarily that segment dealing with the clinical care of workers, for some time to come.

First, the promise of population-based medicine and a corresponding emphasis on prevention certainly imply a favorable climate for occupational safety and health, but in practice this promise has, by and large, not been fulfilled. High rates of turnover of health plan members have undermined the assumed long-term savings achieved from the use of preventive measures like vaccinations, since the recipient will likely belong to a rival plan when the benefits are realized.

Second, the need to generate revenue and save money has led to an emphasis on seeing more patients—a trend reflected in the data in Chap-