How does managed care affect physicians

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The results in the full sample data were very similar to those in the pooled panel data reported in this article, and they also were highly significant. Due to space limitations, the results for the full-sample data are not reported in the text but are available from the authors upon request. A particular focus is on the changing nature of these relationships over time.

Even if more physicians reported having financial incentives to reduce services in than , measures of the effects of managed care and capitated managed care actually declined.

This may indicate that pressures from other sources are growing, while the effects of managed care and capitation are shrinking. In addition, the pressures on physicians may stem from sources other than payment eg, administrative price limits.

Indeed, the literature suggests the financial incentives for physicians come from 3 different sources: 1 how the insurance plan is paid, 2 how the practice organization is paid, and 3 how the physician is paid.

The declining role of managed care in establishing financial incentives to limit care seems to suggest that managed care is itself becoming less restrictive, as others have noted. That is, traditional indemnity plans may be more likely to question procedures and services, much like their managed care counterparts.

In any event, managed care and traditional indemnity plans were substantially more similar in their effects on physician incentives to provide care by than they were just 3 years earlier. Funding Source : None reported. Author Disclosure: The authors HF, JAR report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to : John A. E-mail: john. A national survey of the arrangements managed care plans make with physicians. N Engl J Med. The alignment and blending of payment incentives within physician organizations. Health Serv Res. Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State.

Am J Manag Care. Josephson GW, Karcz A. The impact of physician economic incentives on admission rates of patients with ambulatory sensitive conditions: an analysis comparing two managed care structures and indemnity insurance. Morreim EH. The primary care physicians who responded to the survey were highly experienced with managed care. As a group, they had spent an average of 9. The respondents' average age was The majority of the group reported being involved with independent practice associations and preferred provider organizations.

Figure 1 , Figure 2 , Figure 3 , Figure 4 , and Figure 5 contain the major results of the study. The attitude items in the survey were 5-point Likert scales. For the purpose of summarizing, these are collapsed into 3 levels.

Those that ranged from strongly agree to strongly disagree are discussed as agree response 4 or 5 , neutral response 3 , and disagree responses 1 and 2. Scales from very negative to very positive are handled similarly, with "positive" and "negative" used as descriptors. Although the scales rated from "very infrequently" to "very frequently" do not have a neutral midpoint, we report the 2 highest responses as frequent and the 2 lowest as infrequent.

The number of responses to each question varied, ranging from to Figure 1 , Figure 2 , Figure 3 , and Figure 4 and from to Figure 5. Figures are representative of our findings. In Figure 1 the impact of managed care on primary care physician—patient relationships and Figure 3 on quality of care , negative responses were much more frequent than positive ones on every item. On Figure 2 impact on ethical obligations the pattern was similar, with 1 or 2 exceptions and with several items for which a neutral impact was the overwhelming perception.

Figure 4 the impact of managed care on patients also shows a preponderance of negative perceptions, with 1 exception. Only in Figure 5 on the realization of the goals of managed care is there a true mix of positive and negative perceptions.

Men exhibited an overall more positive attitude toward managed care in this survey than did women. There was not a single scale on which women were statistically more positive about managed care than men. The sex differences, while often highly significant, were of small to modest magnitude. On our Likert scales, with a range of 1 to 5, none of the significant differences listed above exceeded a mean difference of 0.

The average difference in this set was 0. Calculated as Spearman correlations with sex, none of the correlations exceeded an absolute value of 0. Given the small magnitude of the associations and the non-normally distributed scale data, attempting to adjust for possible confounding by such factors as age and time in practice is probably not appropriate. Suffice it to say that these sex differences are essentially descriptive. Five of the comments were not classifiable.

The physicians' statements ranged from simple opinions to emotion-laden commentary. We present representative comments from each category. The cost of immunizations is productive and the emphasis on prevention has always been what pediatricians do. Two commented on good possibilities for physician-patient relationships and quality of care:. The many negative comments related to the ethics of managed care and its effects on physician-patient relationships and quality of care:.

Managed care seems to feel most obligated to run efficiently and be responsible to stockholders, [and to] make medical decision base on population-based norm. A bad one is much worse under managed care. On physician-patient relationship and quality of care the comments included the following:. I mean a minute appointment may take 10 re: insurance issues. The physician, in my opinion, has inherent ethical obligations that no system should interfere with and in my practice no system does interfere with.

I have a feeling that the managed care companies present a conflicting picture to me and perhaps to other doctors. On the top hand, they are a business to make a profit from a patient who is ill and to do this, they must try to limit services they call this efficiency. On the other hand, they, some, are beginning to encourage doctors to think clearer in terms of the science, the personal and the financial aspects of medicine.

Only one [managed care company] is taking an educational role; I feel this needs to be expanded to other companies. I also believe they should set aside a portion of profits for research and education.

They may be a force for betterment some day but now, at the genesis, they need to effect changes in aims, philosophy and planning. Can this occur? If enough pressure is applied and the consequences for not doing this are clarified, it may occur.

The physician respondents to our survey have significant concerns about the effects of managed care on their relationships with patients, their abilities to carry out their ethical obligations to patients, and their capabilities to provide high-quality care. While respondents indicated that managed care was having positive effects in the areas of prevention and reduction of expenditures, and some acknowledged the potential of managed care, most respondents expressed negative views overall.

The negative feedback offered by the physicians in this study closely follows predictions that commentators 3 , 5 , 8 , 10 in the field have made about possible negative effects of managed care.

This feedback may be helpful in highlighting areas that need improvement in current health care delivery systems. Positive physician-patient relationships are essential for effective medical care.

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.

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 effectively 3 and protect patients from overtreatment 32 and unnecessary tests.

Gatekeeping becomes problematic if financial incentives are linked to restricting medical care. Providers may underuse appropriate services and treatments. An essential attribute of the physician-patient relationship is mutual trust. By asking closed-format questions, we have constrained the respondents' ability to express their detailed views about the managed-care tools and to explain the reasons for their ratings. Another limitation is that we did not provide definitions of the terms employed.

This, and similar differences in other definitions, may have added unexplained variance to the opinions. The moderate response rate, although typical for doctor surveys, raises the issue of selection bias.

Respondents may have been more critical toward managed care than non-respondents, but have no data to substantiate this belief. We conducted this survey among a population of doctors who work within a given health system. Our results may be safer to generalize to contexts where the ethos of independent liberal practice is still present. However, more general findings may be valid regardless of context: e. But generalisability is an empirical question, and defining the validity of our results in other contexts would require further surveys.

Regarding the issue of familiarity, we did not document each doctor's experience with each of the tools, beyond participation in a managed care organisation. In some cases, therefore, the rating reflected expectations, in others, experience. These situations are not equivalent and averaging opinions of these types of respondents may result in loss of information.

Finally, this study concerned itself only with the opinions of doctors. Other stakeholders in the health care system may have valid, yet different, opinions about the same managed care tools. Doctors in Geneva, Switzerland, expressed a positive attitude only toward the use of guidelines and otherwise held predominantly negative opinions about managed care tools.

They were particularly severe concerning selective contracting, utilization review, and pay for performance. While they agreed that several measures can help control health care costs, they were particularly concerned about loss of autonomy, worsening of relations with patients, and reduced quality of care.

While we did not query the respondents about their preferences, our results suggest that managed care tools and incentives that remain at least partially under control of the medical profession and that interfere the least with the current payment mechanisms may have the greatest acceptability.

From a policy perspective these generally negative attitudes are informative, as they may influence attempts at implementing managed care tools on a larger scale. Further research in this area should address the following: qualitative analysis of doctors' opinions, assessment of various combinations of managed care tools from the doctors' perspective, and assessment of the opinions of the general public regarding these policies. Iglehart JK: The American health care system.

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Soc Psychiatry Psychiatr Epidemiol. Mansfield CD: Attitudes and behaviors towards clinical guidelines: the clinicians' perspective. Qual Health Care. Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Thomas V Perneger. 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.