The Human Resources Department at your new job is now offering managed care plans. As a consumer, you want to research how the new plans would affect the type of services you would receive.
Instructions
Survey studies have shown that physicians believe managed care is having significant impact on many of their professional obligations.
Methods Primary care physicians were asked about the impact of managed care on: (1) physician-patient relationships, (2) the ability of physicians to carry out their professional ethical obligations, and (3) quality of patient care. In 1996 we surveyed 1011 primary care physicians in Pennsylvania. The survey group's responses were graded on a Likert scale. Space was provided for respondents to include written comments. The SPSS statistical software (SPSS Inc, Chicago, Ill) was used to analyze the data.
Results The response rate was 55%. Most respondents indicated that under managed care physicians are less able to avoid conflicts of interest and less able to place the best interests of patients first. The majority responded that quality of health care is compromised by limitations in location of diagnostic tests, length of hospital stay, and choice of specialists. A significant minority (27%-49%) noted a decrease in the physician's ability to carry out ethical obligations, to respect patient autonomy, and to respect confidentiality in physician-patient communication. Most physicians expressed that managed care made no impact on ability to obtain informed consent or to provide information. There were small but statistically significant sex differences, with female physicians more negative toward managed care.
Conclusions Many physicians surveyed believe managed care has significant negative effects on the physician-patient relationship, the ability to carry out ethical obligations, and on quality of patient care. These results have implications for health care system reform efforts.
Physician-patient relationships
Positive physician-patient relationships are essential for effective medical care.28-30 About two thirds of survey respondents indicated that managed care has a negative impact on physician-patient relationships. Respondents' choices on other survey questions may indicate some of the likely causes.
Most respondents indicated that they have less time for their patients because of emphasis on increased productivity under managed care. Any health care reform that is aimed at reducing costs is likely to result in productivity pressures. Physicians, to maintain their incomes, may be seeing more patients. If the perceptions of this physician group are accurate, many patients may have diminished roles in making medical decisions under managed care, since patients' levels of participation in decision making is related to length of office visits and duration of their relationships with physicians.31In a separate question, most respondents indicated that managed care had adverse affects on patient choice in medical decision making.
Most respondents noted that patients perceive them as adversaries because of their gatekeeper roles. At its best gatekeeping can be a positive activity, in which physicians use their knowledge of the medical system to shepherd patients through most effectively3 and protect patients from overtreatment32 and unnecessary tests. Gatekeeping becomes problematic if financial incentives are linked to restricting medical care. Providers may underuse appropriate services and treatments.33 A Boston-area survey25 examined the attitudes of physicians who served both as primary care gatekeepers for a managed care health plan and as providers for patients with traditional indemnity insurance, and found that many believed gatekeeping had negative effects on the physician-patient relationship, freedom in clinical decisions, time spent with patients, and ease of ordering expensive tests or procedures.
An essential attribute of the physician-patient relationship is mutual trust.9,34,35 Most respondents indicated that patient trust in the physician is diminished under managed care. This survey result is in agreement with other published surveys.15,36 Nearly half of the respondents indicated that the physician's ability to put the patients' interests first was compromised under managed care. Perhaps patients worry about this as well, and have become more wary of their physicians. Patients' concerns are likely heightened by the many articles about managed care in the lay press that echo concerns about expanded physician responsibilities to other groups, including contractual obligations to managed care plans,37 and about how the need to conserve costs could challenge physicians' abilities to maintain loyalty to patients.38 Because of the changing role of physicians within a managed care system, some authors4,5 have raised the concern that physicians may come to see themselves more as economic commodities and less as professionals with obligations to uphold. Such a diminished sense of obligation to professional mores could eventually undermine physician-patient trust.
Some authors10 have predicted that managed care could result in problems in communication between physicians and patients because of shorter office visits due to demands for increased productivity, and by inflated patient expectations from advertising. Although most respondents agreed with the former and almost half agreed with the latter, only 37% of respondents indicated that there was a negative effect on physician-patient communication. Our questionnaire did not ask physicians to identify other factors that might have favorably impacted on communication.
Ethical obligations
Ethical conflicts that could arise for physicians operating in managed care health systems have been well documented.2,3,10,12,39,40 Most primary care physicians in the survey group believe that managed care diminishes the ability of the physician to place the patient's interest first and to avoid conflicts of interest between patients and physicians' financial incentives. Forty-nine percent indicated negative effects on their abilities to respect patients' autonomy. These findings, coupled with the concerns expressed by respondents that under managed care cost cutting takes priority over quality of patient care, indicate that managed care results in troubling conflicts of interest for physicians, and that patient care may be compromised under these systems. In fact, in the open comments, the survey respondents were often passionate about the conflicts of interest and decreased services to patients. Since only 15% of the total survey group responded with such negative open comments, we do not know if those strong views represent a vocal minority or are more widely shared.
Fewer physicians cited negative effects on other ethical obligations. Most physicians in the survey group do not find the informed consent or information-giving processes to be impaired under managed care. We cannot explain how the physicians weighed the demands of increased productivity and shorter visits on the ability to provide information and engage in the informed consent process with patients. Other authors have commented that the informed consent process may be compromised by subtle choice limitations dictated by economic concerns, either at the level of the physician2 or at the level of benefits negotiated by health care purchasers.8 Despite the observations of our survey group that patient choice is limited under managed care, most did not indicate that informed consent was being significantly affected.
One third of respondents indicated that physicians are less able to respect patient confidentiality under managed care. Although managed care often uses quality assurance techniques such as individual patient chart reviews and computerized data banks for utilization and quality reviews,41 many physicians may not view this access to patient information as a meaningful violation of patient confidentiality.
The continuity of the physician-patient relationship is a central obligation for practitioners of clinical medicine.42 More than half of the respondents believe that continuity of the primary care physician–patient relationship has been negatively affected by managed care. Changes in managed care plans offered by employers, and insurance changes due to job changes, have affected continuity of care. In a recent survey,43 physicians self-reported that they had lost an average of 9% of their patients due to insurance plan changes. A 2-year longitudinal study using patient questionnaires found continuity to be higher in fee-for-service systems than in prepaid health care systems.
It is likely that our respondents were comparing managed care with fee-for-service, a system that has the potential to cause ethical conflicts for physicians. The fee-for-service system encourages overutilization of resources, which may result in the provision of unnecessary and possibly detrimental services.3 Still, our data appear to raise new concerns in the areas of respect for autonomy, conflict of interest, and continuity of care.
Quality of care
Most of our physicians identified decreased patient choice in medical decisions as having a negative impact on the physician-patient relationship, which could adversely affect care as well. Most also identified limitations in choice of specialist, in frequency of specialist visits, in sites of diagnostic testing and procedures, and in length of hospital stay as having a negative impact on the overall quality of patient care. Limiting options for care is one of the main methods that managed care systems use to control health care utilization. While limiting options is not necessarily bad for the quality of patient care, most physicians responding to our survey believe that at least some limitations in health care are detrimental. Federal and state legislatures have begun to respond to concerns regarding choice, with the passage of direct-access laws that would allow patients to see specialists without a referral from the primary care providers.44 Limiting choices in medical care is only one way that quality of care can be affected. Most respondents believed that managed care frequently provides better preventive services, and the largest group believed that managed care frequently decreases expense. Physicians in other survey studies25 have expressed similar opinions about cost cutting and preventive care. While physicians' attitudes on quality of care do not substitute for more objective evidence, they identify areas for further investigation when designing quality evaluations.
Sex differences
Women physicians were significantly more likely to report negative effects of managed care in areas of physician-patient relationship, effect of limitations on quality of care, and on the effects of managed care on time available to spend with patients. Sex differences in practice style between male and female physicians have been documented,45,46 and may have a role in the sex differences found in this study. The effect of sex on attitudes toward managed care needs to be explored in greater detail.
Most other surveys about physicians' attitudes toward managed care have generally been part of larger surveys designed to elicit a wide variety of views from physicians. The 1996 American Medical Association survey36 found even greater negative physician sentiment toward managed care. Eighty-one percent of the physician respondents viewed the impact of managed care on the physician-patient relationship as negative. Seventy-one percent saw managed care as having a negative impact on quality of care. This group was significantly less involved with managed care, with 43% noting that less than 20% of their patients were covered by a managed care plan. A survey conducted by the Texas Medical Association26 found that half of the physician respondents believed that managed care has an adverse impact on patient care. Another survey,15 looking at the attitudes of primary care physicians toward capitated reimbursement, a common feature of managed care, found that physicians believe that capitation is having a negative impact on the physician-patient relationship and on the appropriate use of referrals and services. These previously published surveys support the concerns of the physician respondents in our survey. Our survey extends the findings of these survey studies by providing physicians' views on specific aspects of the physician-patient relationship, and ethical obligations under managed care overall.
It is still an open question as to whether physicians' attitudes on these issues reflect decrements in quality care or patient outcomes. Studies17-23 on outcomes and quality-of-care issues in managed care systems have shown both positive and negative changes. Patients may be more positive about managed care. The Health Tracking Initiative and the Community Snapshots study16 surveyed 300 health care consumers in 15 communities in 1995. The findings of this study show the users of health care to be positive toward managed care, with 59% regarding the shift toward managed care as being beneficial. That survey did not report on the patients' views on the impact of managed care on the physician-patient relationship, or on medical ethics, but revealed that most respondents believed that managed care would have a positive impact on health care.
The design of our survey has several potential limitations. A broad definition of managed care was offered to the physician respondents, because we were aiming to elicit their general perceptions about practice under managed care. However, physicians' views are likely influenced by the specific managed care contracts that they are participating in. There may be subgroups of physicians whose views are either more positive or more negative because of the specific terms of their contracts. The findings of our study make such investigation more imperative. The Delaware Valley region had a distinct health care profile at the time of the study. The area had been highly penetrated by managed care, particularly of the HMO and independent practice association model and point of service enrollment. In 1996, Singer and Company research group27 reported that the combined penetration rate of HMOs, preferred provider organizations, and point of service enrollment in the region was 67%. As of 1995, reimbursements in this region were 50% by capitation, 25% by fee-for-service, and 25% by other arrangements.47 Our findings may not be replicable in other geographic regions in which other models are more prevalent. Although our response rate was a respectable 55%, we have limited information about nonrespondents. Specialty and sex distribution were similar between the respondents and nonrespondents, and nonrespondents participated in the same managed care organizations since the mailing list was derived from 4 provider handbooks, but we cannot generalize to the entire sample. Survey questions were written in the third person, asking about the profession in general and not about personal experiences. However, many respondents' written comments reflected personal experiences, substantiating their responses to questions. Many respondents appear angry at their loss of control, autonomy, and income. It is likely that this anger affects some physicians' appraisals of the deleterious effects of managed care.
Since our survey was completed, managed care has already begun to assume new configurations, partially in response to public backlash against managed care.48 Some managed care organizations have made changes that expand patient choice by permitting patients to bypass the primary care physician in seeking out specialist care. Other plans allow patients to seek care from providers outside of the health plan for an increased fee.49 Whether changes like these will improve the perceptions of physicians that managed care is having profound effects on the physician-patient relationship, quality of care, and on their ability to carry out their ethical obligations remains to be seen.
A wider variety of physicians must be surveyed on the issues raised herein. More detailed questions on the relative weight of the different aspects of the physician-patient relationship need to be asked to better understand the reasoning behind physicians' attitudes on these topics. Structured interviews conducted with physicians working in a variety of reimbursement systems would help to further elucidate the effects of managed care on the ethical foundations of medical practice and on quality of care. Some respondents commented that managed care has had an especially negative impact on mental health care, which is consistent with some emerging literature.50-53 Questions about the impact of managed care on mental health care should be included in future surveys. In addition, although a complex task, it is important to try to correlate the views of patients on these issues with those of the physicians. Such information would be valuable in guiding further health care reforms, including the many legislative efforts to regulate managed care now taking place,44,48 as well as more innovative suggestions to establish nongovernmental standard-setting bodies for managed health care.6,54
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