Why are physicians so upset about managed care?

A method for estimating relative complexity of ambulatory care

PURPOSE

We wanted to demonstrate a method for calculating the relative complexity of ambulatory clinical encounters.

METHODS

Measures of complexity should reflect the complexity of the typical encounter and across encounters. If inputs represent the information transferred from the patient to the physician, then inputs include history, physical examination, testing, diagnoses, and patient demographics. Outputs include medications prescribed and other therapies used, including education and counseling, procedures performed, and disposition. The complexity of each input/output is defined as the mean input/output quantity per clinical encounter weighted by its inter-encounter diversity (range of possibilities used) and variability (visit-to-visit change). In complex systems, as the information in the input increases linearly, the complexity of the system increases exponentially. To assess the impact of the complexity of the encounter on the physician, we adjusted the estimated complexity by the duration-of-visit.

RESULTS

Using the 2000 NAMCS database, we calculated input and output complexities for 3 specialties. Construct validity was affirmed by comparing the relative rankings of complexity against relative rankings using other complexity-related measures. Although total relative complexity was similar for family medicine (44.04 +/- 0.0024 SE) and cardiology (42.78 +/- 0.0004 standard error [SE]), when adjusted for duration-of-visit, family medicine had a greater complexity density per hour (167.33 +/- 0.0095 SE) than either cardiology (125.4 +/- 0.0117 SE) or psychiatry (31.21 +/- 0.0027 SE).

CONCLUSIONS

This method estimates complexity based on the amount of care provided weighted by its diversity and variability. Such estimates could have broad use for interphysician comparisons as well as longitudinal applications.

A doubtful guest: managed care and mental health

This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.

Managed care and systems cost-effectiveness: treatment for depression

OBJECTIVE

The objective of this study was to assess the change in system cost-effectiveness of depression treatment after the introduction of managed care.

DATA SOURCES/STUDY SETTING

The study population consisted of adults ages 18 to 69 living in low-income areas of Puerto Rico.

STUDY DESIGN

Using a random probability sample of the population, 2 waves (1992-1993, 1993-1994) of data were collected before implementation of managed care and one wave (1996-1998) after implementation. Composite International Diagnostic Interview (CIDI)-generated depression diagnoses and Centers for Epidemiologic Studies-Depression (CES-D) scale of depressive symptoms scales were used to assess depression.

DATA COLLECTION/EXTRACTION METHODS

Effectiveness of treatment was defined by guideline standards and experts' assessment of the probability of remission resulting from treatment. Costs were measured by assigning representative prices to each treatment modality. Difference-in-difference (D-in-D) estimators were used to assess the impact of managed care on the effectiveness and costs of treating depression at the system level for the entire population.

PRINCIPAL FINDINGS

System cost-effectiveness improved slightly after the introduction of managed care, with diminished costs but no significant improvements in effectiveness.

CONCLUSION

Cost-effectiveness can be measured at the population level to assess system changes. Additional incentives and system realignments beyond utilization review and diminished treatment costs are necessary to attain a more cost-effective system of care.

Ambulatory care visits and quality of care: does the volume-control policy matter?

Using claims data from the Bureau of National Health Insurance (BNHI) in Taiwan and primary data collected from 940 patients who visited their physicians at out-patient clinics to complete questionnaire, we investigated the effects of the hospital volume control policy on the frequency of visits, medical expenses and patient satisfaction. We found that the volume control policy on ambulatory care decreased physician fees and increased both the number of visits and co-payments. However, it did not result in any change in the total medical expenses. A shift in ambulatory care expenditure from BNHI to patients did not improve patient satisfaction. While the patients were comfortable with the waiting line, they were not satisfied with the providers’ strategy of limiting quota of visits during a period of time.

Managed Care and Patient Safety

OBJECTIVE

Patient safety practices have primarily focused on providers, such as hospitals and ambulatory or long-term care. Based on the premise that most medical errors and patient safety problems arise from system issues, and that managed care constitutes the largest, most integrated system in health care, the authors examine the role of managed care in making patient care safer.

STUDY DESIGN

Review of the literature and analysis of the role of managed care in patient safety.

RESULTS

Authors find that although much has been written regarding managed care and quality, there is little research on managed care's relationship to patient safety. Research shows that managed care is not significantly different from indemnity insurance in terms of quality of care. However, managed care contracting, reimbursement, and management practices result in health care utilization changes that could pose potential risks for patient safety. Although managed care may pose possible risks to patient safety, practices can be monitored and adjusted to maintain quality and safety. At the same time, managed care provides opportunities for promoting patient safety at an integrated system level. Managed care organizations are in a unique position to influence patient safety by using safety strategies in selective contracting, financial incentives for performance, quality improvement programs, consumer education, and management and integration of care delivery. Our literature review reveals that health plans are starting to implement some of these strategies, but the practice is not widespread.

CONCLUSIONS

Authors conclude with a framework and recommendations for patient safety.

Changing the nature of physician referral relationships in the US: the impact of managed care

Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.

Career Disaffection among Surgeons in the Era of Managed Care

The purpose of this paper is to assess career satisfaction of surgeons in the era of managed care. The method of this assessment is by membership survey of the Southeastern Surgical Congress and the Western Surgical Association. Members were queried about their demographic characteristics, some aspects of the business of their practices, their attitudes toward retirement, their perception of the effectiveness of organized medicine as a socioeconomic advocate, and a comparison of each surgeon's career satisfaction before and during the era of managed care. Three hundred seventy-three usable surveys were returned, computerized, and analyzed statistically. Summaries of categorical variables are presented as percentages for various groupings of the categorical set. Results reveal a broad-based career disaffection in all areas queried, most notably in the business of surgical practice, attitude toward retirement and retirement alternatives, and the advocacy role of organized medicine for their issues. There is an almost unanimous desire for the American College of Surgeons to become their aggressive socioeconomic advocate. The data support a conclusion that surgeons perceive they are not represented in a realistic manner with the insurance companies and the government when their core issues are decided.

Are patients' office visits with physicians getting shorter?

BACKGROUND

Many believe that managed care creates pressure on physicians to increase productivity, see more patients, and spend less time with each patient.

METHODS

We used nationally representative data from the National Ambulatory Medical Care Survey (NAMCS) of the National Center for Health Statistics and the American Medical Association's Socioeconomic Monitoring System (SMS) to examine the length of office visits with physicians from 1989 through 1998. We assessed the trends for visits covered by a managed-care or other prepaid health plan (prepaid visits) and non-prepaid visits for primary and specialty care, for new and established patients, and for common and serious diagnoses.

RESULTS

Between 1989 and 1998 the number of visits to physicians' offices increased significantly from 677 million to 797 million, although the rate of visits per 100 population did not change significantly. The average duration of office visits in 1989 was 16.3 minutes according to the NAMCS and 20.4 minutes according to the SMS survey. According to both sets of data, the average duration of visits increased by between one and two minutes between 1989 and 1998. The duration of the visits increased for both prepaid and nonprepaid visits. Nonprepaid visits were consistently longer than prepaid visits, although the gap declined from 1 minute in 1989 to 0.6 minute in 1998. There was an upward trend in the length of visits for both primary and specialty care and for both new and established patients. The average length of visits remained stable or increased for patients with the most common diagnoses and for those with the most serious diagnoses.

CONCLUSIONS

Contrary to expectations, the growth of managed health care has not been associated with a reduction in the length of office visits. The observed trends cannot be explained by increases in physicians' availability, shifts in the distribution of physicians according to sex, or changes in the complexity of the case mix.