Professional integrity in the age of managed care: views of physicians

Physicians’ Perceptions of Managed Care: A Review of the Literature

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians’ perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

Quality-based procedures in Ontario: exploring health-care leaders' responses

AIM

To examine health-care leaders' initial response to the implementation of orthopaedic quality based procedures (QBPs) in hospitals across Ontario, Canada.

BACKGROUND

In 2012, Ontario, Canada shifted 91 hospitals to a patient-based funding (PBF) approach. This approach funds health-care organisations based on the number of patients treated with select procedures known as QBPs.

METHODS

An exploratory descriptive design was employed to better understand health-care leaders' early implementation experiences. Seventy organisational leaders from 20 hospitals participated in six focus groups and four interviews to discuss their initial responses to the implementation of two QBPs (primary unilateral hip replacement and primary unilateral knee replacement). Qualitative data underwent content analysis.

FINDINGS

Three key major themes emerged; (1) responding to change, (2) leading the change and (3) managing the change. Within each of these themes, barriers and benefits were identified.

CONCLUSION

Leaders are accepting of PBF and QBPs. However, challenges exist that require further exploration including the need for a strong infrastructure, accurate and timely clinical and financial data, and policies to prevent unintended consequences.

IMPLICATIONS FOR NURSING MANAGEMENT

Implementing QBPs requires careful planning, adequate and appropriate resources, vertical and horizontal communication strategies, and policies to ensure that unintended consequences are avoided and positive outcomes achieved.

The Patient Protection and Affordable Care Act (ACA) of 2010 and Ohio physicians

Purpose

– This paper aims to explore the perspectives of Ohio physicians on the Patient Protection and Affordable Care Act (ACA) of 2010. While much has been debated about ACA, relatively few studies have focused on how ACA will impact on physicians' practice behavior.

Design/methodology/approach

– The research data came from a mailed survey of ninety physicians randomly selected from the Cigna Directory of Physicians practicing in Ohio. Study examined how informed were physicians about ACA, and explored how much the effect of ACA has been discussed in their practice, how they think ACA will impact their practice, and whether or not they are in favor of the provisions under the Act.

Findings

– Overwhelmingly, while the physicians surveyed were familiar with the specific provisions of ACA, almost half of them opposed it. Primary care physicians reported generally favorable opinions about ACA. All but one of the physicians concluded that ACA, much like managed care provisions, has undermined and will continue to reduce the autonomy and professional independence of physicians.

Research limitations/implications

– This study is limited by its small sample and reliance on a small set of physicians.

Practical implications

– This study has practical implications for examining how Ohio physicians are responding to the new health care reform in the United States. It has broader implications for addressing the problem of the uninsured and the role of the federal government in health care provision.

Social implications

– If physicians are opposed to this reform as the study seems to suggest, it might have broader implications for future career aspirations for physicians.

Originality/value

– So far as we can tell, there has not been any exploratory study in Ohio examining the perspectives of physicians on ACA.

Managed care regulation in the States: the impact on physicians' practices and clinical autonomy

While the states engaged in an extended period of adopting and revising laws regulating managed care during the 1990s, there has been to date only limited empirical assessment of the impacts of these laws. For this analysis, we constructed a data set using information on state laws combined with survey responses of physicians. We distinguish regulations with a typology based on whether they affect the context or content of care and the target group of the regulation (consumer or provider). Our findings indicate that the context of care appears to be more efficaciously regulated than the content of care. Provisions concerning consumer access and contractual relationships lead to greater reported physician ability to obtain referrals and services, improved quality of clinical interactions, and greater perceived clinical autonomy. Regulations intended to enhance professional autonomy are associated with lower reported levels of utilization constraints and higher reported quality of clinical interactions. In contrast, consumer protection provisions, including procedures for appeals from plan decisions, appear to have had little impact on most physicians' practices. Despite structural and legal constraints on the potential effectiveness of these regulations, state managed care legislation appears to have provided some protections against managed care restrictions on physicians' clinical autonomy.

Quality of patient referral information for open-access endoscopic procedures

BACKGROUND

Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety.

OBJECTIVE

To assess the accuracy of endoscopic referral information.

DESIGN

Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records.

SETTING

Large academic medical clinic.

PATIENTS

A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services.

MAIN OUTCOME MEASUREMENTS

Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies.

RESULTS

Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy.

LIMITATIONS

Study limited to an academic clinical setting.

CONCLUSIONS

Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.

Profit-seeking, corporate control, and the trustworthiness of health care organizations: assessments of health plan performance by their affiliated physicians

OBJECTIVE

To compare the relative trustworthiness of nonprofit and for-profit health plans, using physician assessments to measure dimensions of plan performance that are difficult for consumers to evaluate.

DATA SOURCE

A nationally representative sample of 1,621 physicians who responded to a special topics module of the 1998 Socioeconomic Monitoring System Survey (SMS), fielded by the American Medical Association. Physicians assessed various aspects of their primary managed care plan, defined as the plan in which they had the largest number of patients.

STUDY DESIGN

Plan ownership was measured as the interaction of tax-exempt status (nonprofit versus for-profit) and corporate control (single state versus multistate health plans). Two sets of regression models are estimated. The dependent variables in the regressions are five measures of performance related to plan trustworthiness: two related to deceptive practices and three to dimensions of quality that are largely hidden from enrollees. The first set (baseline) models relate plan ownership to trustworthy practices, controlling for other characteristics of the plan, the marketplace for health insurance, and the physician respondents. The second (interactive) set of models examines how the magnitude of ownership-related differences in trustworthiness varies with the market share of nonprofit plans in each community.

DATA COLLECTION

The 1998 SMS was fielded between April and September of 1998 by Westat Inc. The average time required for a completed interview was approximately 30 minutes. The overall response rate was 52.2 percent.

PRINCIPAL FINDINGS

Compared with more local nonprofit plans, for-profit plans affiliated with multistate corporations are consistently reported by their affiliated physicians to engage in practices associated with reduced trustworthiness. Nonprofit plans affiliated with multistate corporations have more physician-reported practices associated with trustworthiness than do for-profit corporate plans on four of five outcomes, but appear less trustworthy than locally controlled nonprofits on two of the five measures. The magnitude of these ownership-related differences declines as the market share of nonprofit plans rises: for two of the five measures, ownership-related differences in practices related to trustworthiness are entirely eliminated when the nonprofits enroll more than 30 percent of the local market.

CONCLUSIONS

The combination of for-profit ownership and multistate corporate control appears to consistently and substantially reduce physician-reported measures related to the trustworthiness of health plans. Because this is the fastest growing form of managed care, these results raise concerns about further erosion of trust in American health care. Preserving a substantial market niche for nonprofit plans appears to reduce this erosion and should be considered by policymakers as a strategy for restoring trust in the health care system.