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Ford Motor Co. used to tout in its ads that "Quality is Job One." With health care in recent years, many physicians and patients have said that’s not the case with capitation and managed care. But if you look more closely, you find that there are things doctors hate and things they appreciate about the huge shift in health care delivery. What do they hate?
What do they appreciate about the changes?
• Scoring systems that financially reward physician productivity. Physicians whose compensation is affected by meeting quality measures tend to perceive that type of payment system as appropriate.
• Practices that take patient satisfaction surveys seriously. For instance, capitated physicians are the strongest advocates of patient self-care, says Judith H. Hibbard, PhD, a Robert Wood Johnson researcher and professor of planning, public policy and management at the University of Oregon in Eugene.
• Group practices that have the management skills to buffer physicians from the downside and maximize ways to improve patient care. For example, two positive outgrowths of managed care pressures are that some practices have developed skills at making specialist referrals a manageable process, and they are integrating what patients are asking for in surveys.
If changes are in the offing, it’s advisable to look more closely at what works and what doesn’t, says James Reschovsky, PhD, lead researcher for the Washington, DC-based Center for Studying Health System Change. "The managed care backlash’ is predicated on concerns about quality of care and has led to numerous legislative proposals to regulate managed care plans," points out Reschovsky and colleagues, who recently published findings based on the Community Tracking Study Physician Survey of 12,365 physicians.1
Capitation often tops the list of complaints from many doctors. "The concerns appear to be fueled more by anecdotes than by systematic empirical evidence," Reschovsky says. That’s largely because of measurement constraints. Methodologies for comparing clinical results under various modes of care systems are adding to our knowledge base, but they still show inconsistent findings. Most scientists agree the results lack comparability.
Until that discipline is perfected, the next best strategy is to measure and compare physician perceptions of quality in managed care and non-managed care settings, Reschovsky and team assert. That’s the approach they took in an effort they bill as the "largest and most comprehensive study with a large, nationally representative sample of patient care physicians."
The team investigated how aspects of physicians’ exposure to managed care are associated with perceptions of their ability to provide high quality of care. In reviewing survey responses, researchers drew six key "lessons learned" from physicians’ experience with capitation and related managed care issues:
1. More than two-thirds of physicians express minimal concerns about quality, while the remainder have quality of care anxieties. Between 21% and 31% of physicians disagreed with the quality statements. This suggests that between one-fifth and one-third of doctors overall believe that the quality of care they deliver is being compromised to some degree.
2. Specialists express more disdain for managed care than primary care physicians (PCPs) do. Specialists were 50% more likely than primary care physicians to express concerns about their ability to provide high-quality care under managed care constraints. This may largely stem from pocketbook issues, the study says. "Specialists are more likely than PCPs to have lost income and some control over the management of patient care as a result of managed care," Reschovsky and team note. "Consistent with this, previous studies have found specialists to be more dissatisfied."
3. Juggling multiple contracts complicates practice management. A negative perception of quality of care was not associated with the percentage of practice revenue from managed care; rather, there was an association between a negative quality perception and the number of managed care contracts the physician’s practice had. Plan structures are already changing to respond to consumer complaints, but at the same time, health care spending is back on the rise, according to Katharine Levit, director of the National Health Statistics Group of the Health Care Financing Administration in Baltimore.
4. Market environment has a huge impact. The level of market penetration of managed care in a physician’s geographic area is directly related to the doctor’s level of confidence in his or her ability to deliver high quality of care. The more crowded and competitive the insurance market is in a particular area, the more anxiety doctors feel in their practices. For instance, those in high managed care markets (50% or more revenue from managed care) were 10% less likely to agree that they have adequate time with patients and were 16% less likely to agree with the continuity of care measure. That’s compared with physicians practicing in markets with 30% or less physician revenue from managed care.
5. There is strength in numbers. Well-run group practices make it all a lot easier, respondents said. Physicians in groups expressed fewer concerns about managed care pressures and fixed payment issues than physicians in solo and two-physician practices. That trend is even more pronounced when the group is well-established rather than in a fast-paced growth mode.
6. Specific financial incentives and care management tools, which have flourished under capitation and other managed care systems, garner mixed reviews from doctors. For example, physicians whose income is affected by quality and productivity scores show more confidence that managed care techniques deliver appropriate quality of patient care. But two of the icons of managed care "care management" technologies — written guidelines and practice profiling — are perceived as less likely to improve patient care. Patient satisfaction surveys that are taken seriously by a practice, however, are perceived positively.
These findings are based on measuring physician agreement levels with seven statements related to quality of care. Their data came from the Community Tracking Study Physician Survey, a cross-sectional, nationally representative telephone survey. The response rate was 65%. Physicians who took part provide direct patient care for more than 20 hours a week, excluding federal employees and those in selected specialties.
1. Reschovsky J, Reed M, Blumenthal D, Bruce L. Physicians’ assessments of their ability to provide high-quality care in a changing health care system. Med Care 2001; 39:254-269.