The managed care backlash: perceptions and rhetoric in health care policy and the potential for health care reform

The focus on managed care and the managed care backlash divert attention from more important national health issues, such as insurance coverage and quality of care. The ongoing public debate often does not accurately convey the key issues or the relevant evidence. Important perceptions of reduced encounter time with physicians, limitations on physicians' ability to communicate options to patients, and blocked access to inpatient care, among others, are either incorrect or exaggerated. The public backlash reflects a lack of trust resulting from cost constraints, explicit rationing, and media coverage. Inevitable errors are now readily attributed to managed care practices and organizations. Some procedural consumer protections may help restore the eroding trust and refocus public discussion on more central issues.     

Academic public health and managed care.

Health care delivery is going through revolutionary changes. There is a shift toward providing care under the auspices of managed care organizations (MCOs). These MCOs are becoming larger and more comprehensive while increasingly focused on preventive and public health issues. Quality of care, health economics, health services research, data and information systems, quantitative analysis, and the social and behavioral sciences are all becoming important areas of expertise for MCOs and are vital to their successful operation. Thus schools of public health can contribute considerably to MCOs by making their curricula relevant to a managed care environment and having faculty members and research programs that recognize the public health overlap with managed care.     

Physician and plan effects on satisfaction of Medicaid managed care patients with their health care and providers

As many Medicaid patients move into managed care, it is important that physicians competing to serve these patients understand the factors that lead to patient satisfaction. This study uses survey data from 7,313 Oregon Medicaid managed care patients to create a model describing how provider effects and health plan effects relate to patients' satisfaction with their medical care and provider. Path analysis was used to test the explanatory power and strength of relationships in the model. Perceived technical and interpersonal physician quality and health plan rating were most strongly linked with these patients' satisfaction with their care and provider.     

Family physicians' observations of their practice, well being, and health care in the United States.

OBJECTIVE: Our goal was to characterize how family physicians perceive recent changes in the health care system and how content they are with various factors. STUDY DESIGN: We performed a cross-sectional mailed survey. POPULATION: The survey was completed by a random sample of 361 family physicians practicing in the United States. OUTCOME MEASURES: The survey evaluated attitudes about corporate managed care, health care reform, career satisfaction, compensation, personal life satisfaction, workload stress, personal well-being, and residency training. We reported percentages for Likert-rated survey items, factor analysis of the survey, and a regression model for statistical prediction of the 4 major factors. RESULTS: Relative to survey data gathered in 1996, fewer family physicians in our survey reported that they were satisfied with their careers (59% vs 82%); fewer were satisfied with their compensation (55% vs 65%); and fewer would again choose family practice as their specialty (66% vs 75%). Thirty-one percent worried that they were "burning out" as physicians, and 48% reported that they had experienced more stress-related symptoms in the past year. Only 7% agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford, but only 36% unequivocally endorsed the concept of a national health plan. Forty-two percent of the respondents reported that they had witnessed bad patient outcomes they perceived to be attributable to managed care business processes. CONCLUSIONS: The morale and career satisfaction of family physicians seems to have eroded in recent years, and discontent is common. As a group, family physicians are unhappy with the current health care system and quite unified about certain specific reforms, yet they are far from such consensus about more sweeping reform.     

Use of health care services following mandatory retirement

I examined the use of health care services before and after mandatory retirement. Data were collected from provincial medical care and hospital insurance records for each of 88 retirees. Interview data provided information about selected psychosocial and health factors which earlier studies found to be related to health status. Two patterns in use of health care services were found: in one group (N = 54), use of health care services increased and in the other group (N = 34), use of services decreased following mandatory retirement. Discriminant analysis procedures were applied to determine which factors could predict group membership. Two factors were found to be important for correct identification of group membership: part-time employment and including all food groups in the diet on the day before the interview. Based on this combination of factors, group membership could be correctly identified 55% of the time for the increased usage group, and 82% of the time for the decreased usage group.     

Physician perceptions of health care reform: national versus state knowledge, input and support

Health care reform directly impacts physicians and the practice of medicine. A questionnaire was sent to a random sample of 2,000 physicians in the state of Florida to obtain physician perceptions of health care reform. Physician knowledge, input, and support of both state and national health care reform were reported in the lowest categorizations. Issues deemed most important for support were tort reform and physician autonomy. The approach of the Florida plan, managed competition, was viewed as ineffective in addressing the issues of cost and access. Experience with the managed competition model and objective evaluations may alter perceptions and increase physician support.     

Exploring the disparities of regional health care expenditures in Switzerland: some empirical evidence

This study investigates the determinants of regional variations in health care expenditures (HCE) in Switzerland, since there are significant differences between cantons per capita HCE. The empirical analysis contributes to the discussion on the outcome of federalism in the Swiss health care system by improving the understanding of the determinants of the differences in HCE. Our econometric estimations indicate that HCE are significantly related to the density of specialist physicians, density of dispensing doctors, per capita income, proportion of managed care, medical and technological progress and socio-economic factors. Due to the presumptive importance of the organisation of ambulatory care, we suggest policy makers should particularly concentrate on promoting the supply of managed care models in Switzerland. Supporting the development of managed care may help to countervail some of the influences which tend to lead to higher cantonal health expenditures.     

Managed care and the public health challenge of TB.

Managed care is fast becoming the dominant form of medical care delivery and financing in the United States, yet its effects on public health practice remain largely unknown. Tuberculosis (TB) is a classic example of a disease with both public health and medical care implications, and as such it provides an opportunity for examining the impact on public health of the shift towards managed care in the medical marketplace. The authors approach the role of managed care in TB control by first considering the need for interorganizational coordination at the community level. The authors identify four basic models of how managed care organizations may fit into TB control efforts in local communities, using observations from 12 local public health jurisdictions to illustrate these models. These TB control models provide insight into the general mechanisms through which managed care organizations may affect other areas of public health practice.     

The current state of health care in the former Soviet Union: implications for health care policy and reform.

OBJECTIVES. Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process. METHODS. Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research. RESULTS. Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion. CONCLUSIONS. Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.     

Measuring the physician perspective on quality of care in health plans

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.     

The transfer of a health insurance/managed care business

The owners of a health insurance/managed care business may want to sell that business for a variety of reasons. Health care provider systems may want to exit that business due to operating losses, difficulty in complying with regulations, the inherent conflict in operating that business as part of a provider system, or the desire to focus on being a health care provider. Health insurers/HMOs may want to sell all or a portion of their business due to operating losses, difficulty in servicing a particular market, or a desire to focus on other markets. No matter what reason prompts a seller to undertake a sale, a sale of health insurance/managed care business can be a complicated transaction involving a multitude of issues. This article will focus first on the ways in which such a sale may be structured. The article will then discuss some transactional issues that may arise in the negotiations for the sale of a health insurance/managed care business. The article will then focus on some particular legal issues that arise in each sale-e.g., antitrust, HIPAA, regulatory approvals, and charitable issues. Finally, this article will provide an overview of tax structuring considerations.     

How mental health providers see managed care

This paper reports findings from two focus groups on managed care conducted in a large U.S. city in 1989. Questions addressed included how managed care had affected mental health practice, specific experiences with managed care, the mechanisms of managed care, and how managed care could be improved. The practitioners complained of multiple problems, but clearly distinguished between “good” and “bad” firms. Firms seen as more positive struck a balance between quality care and cost containment, built ongoing relationships with providers, and negotiated with providers, rather than prescribing a treatment plan. The authors conclude that some of the poor reception by providers of managed care may have been created unnecessarily by firms which have not attended to those factors, and that attention to such factors might lead to a more ready acceptance of managed care.     

Forecasting the health care future. Futurescan 2001 and its implications for health care marketing

In his new book, futurist Russell C. Coile Jr. presents predictions about seven aspects of health care for the next five years. Aided by a panel of health care experts, he analyzes likely developments in health care consumerism, technology, managed care, and other areas that raise a number of issues for health care marketers. Even if only a few of these predictions come true, marketers will be forced to rethink some of their techniques to adapt to this rapidly changing environment.     

Indian student doctors'' attitudes towards primary health care, poverty and related issues

An attempt is made to study the attitudes of student physicians towards primary health care, poverty, and related social issues in India. The sample consisted of 464 men and 228 women final-year medical students (a total of 692) from 11 medical colleges in India. An open-ended questionnaire was used. Content analysis was performed on the responses. There were no statistically significant differences between the responses of the students belonging to different socio-economic groups. There were some differences in the responses of the men and women students, especially on the question of poverty and related social issues. The data presented here show that the student physicians do not have a clear understanding of the primary health care approach, or about the social issues that influence health. This study underlines the need for exposing student physicians to the essential aspects of poverty and its impact on health and the importance of the primary health care approach for providing health care to disadvantaged groups.     

Managed care and the US health care system a social exchange perspective

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.     

School-based health centers and managed care health plans: partners in primary care.

School-based clinics provide important access to health care for adolescents. For the past 20 years in St. Paul, Minnesota, Health Start has been a nonprofit organization providing comprehensive primary care services in the city's public high schools. Over the past decade, Minnesota has seen the growth of managed care plans for both the private and public (Medicaid) sectors. For the past several years, Health Start has been building relationships with managed care plans in order to coordinate care for adolescents. Since managed care plans differ in their management, reimbursement, and service delivery methods, Health Start has developed several models of partnership with managed care plans for the delivery of primary care to adolescents enrolled in school.     

Public health competencies required by managed care organizations.

The authors developed a list of population-based public health competencies. They surveyed the chief executive officer, chief medical officer, and chief quality control person at a randomly selected group of managed care organizations drawn from the membership of the American Association of Health Plans. The authors asked them to rank those competencies that were essential for them in their work with their organization. The authors identified both the most commonly required competencies across all groups and the most essential for each specific job in the managed care organization. This article discusses these competencies and their implications for those who are responsible for ensuring that graduates have achieved required competencies.     

Satisfaction with organizational aspects of health care provision among Lithuanian physicians

BACKGROUND: Physician satisfaction is considered an important factor influencing quality of health care provision, patient compliance, and costs to health care systems. Dissatisfaction leads to an increase in turnover of physicians and early retirement, which has a negative impact on continuity and quality of health care. Physician dissatisfaction with certain aspects of health care provision may also help to identify potential weaknesses in satisfactory functioning of health care systems. The aim of the current research project is to study the satisfaction with different organizational aspects of health care provision in Lithuania as judged by a selection of physicians. METHOD: The study was conducted in Lithuania in June 2004. Physicians in randomly selected health care centers were invited to take part in the survey, 505 primary and secondary care physicians were interviewed by external interviewers during the study period. Physicians were asked to express their satisfaction on items presented in a questionnaire. The questionnaire consisted of 22 questions, evaluating different aspects of health care services - working conditions, workload, financial remuneration, organization of health care infrastructure and availability of laboratory services. Answers were presented by the 5 point Likert type scale, ranging from "very satisfied" (5) to "very dissatisfied" (1). RESULTS: Physicians who were most satisfied with their working conditions were working in private primary health care practices (91.1% satisfied or very satisfied), as compared with 54% of physicians working in state-owned primary care institutions and 49.7% in hospitals. Physicians working in cities and regional centers or towns were more satisfied with organizational aspects of health care services than physicians working in rural health care centers. Satisfaction with their financial remuneration showed that 74% of respondents stated they were "dissatisfied" or "very dissatisfied". While asked about potential deficiencies in their health care institutions, the most important identified by respondents in all localities was a perceived lack of financial support for these institutions. CONCLUSIONS: There is a significant difference in the perception of physicians in private and state health care institutions with regard to financial remuneration as well as availability of laboratory diagnostic and treatment equipment and working conditions. Based on the study findings, possibilities to increase Primary Care financing should be considered in order to improve the quality of the delivery of health care services as well as retain physicians within the health care system. Results of this study demonstrate a need of further research to quantify what could be reasonably expected from diagnostic and investigative resources to support health care in Lithuania in current economic situation.