Positive Aspects of Managed Care
The positive effects of the new health care environment on primary care were apparent both from observations and interviews. Many of the tenets of managed care—such as the need to coordinate care through the primary care provider—have been advocated by family physicians for years and now appear to be reinforced by the new systems (I, F, P, D, E). As one family physician put it, “We’re now doing the things we always wanted to do…like having patients come to us before going to specialists.”
Many of the physicians also recognize that they personally receive direct and indirect financial benefits with managed care (I, F, P). As practice administrators and physician managers at most of the sites admitted, capitation is a better financial deal than fee-for-service had ever been; capitation provides a predictable monthly income and cash up front (I, D). Most practice groups are following the national trend21 and realizing greater profits from capitated patients than from those covered by indemnity or discounted fee-for-service. In addition, some providers voiced their satisfaction at being paid for global care under capitation, not just for clinic or hospital visits (I).
Providers defended managed care’s benefits to patients by pointing out that a growing number of them were getting more types of care with less out-of-pocket expenses (I, F, P, D, E). For example, patients who could not previously afford to pay for preventive check-ups, tests, and immunizations were now covered by their managed care organizations for such services and were receiving them freely (P, E, D). Care providers also noted that in some cases managed care was leading to tighter coordination and case management, and increased disincentives for performing unnecessary procedures (I, F, P, D, E).
DISCUSSION
Competing Ideologies and Moral Values
As observed at the 5 sites, US family practice centers have become ideologic battlegrounds between primary care as a business and as a “calling” Table 3. Those who espouse the notion of family medicine as a beneficent calling perceive its goal in terms of humanistic care for individuals, families and communities, the performance of good acts, and the relief of suffering.22-23 Though physicians have always had to earn a living, they were nonetheless expected to have their patients’ well-being as their primary concern.3 In the managed care era, a new set of convictions, models, and terms has been adopted by many providers who view health care as a managed commodity where economic self-interest is linked to the interests of populations, managed care organizations, and the economy as a whole.
In the current health care environment, there is an ongoing struggle among the managed care organizations’ attempts to turn care providers into their agents,24-25 the patients’ best interests, and the care providers’ professional and personal self-interest. In an age of ambiguous and shifting alliances (provider with insurer; insurer with patient; patient with provider), clinicians are frequently forced to answer, “Whose side are you on?” Table 4.
The Local Reflects the Global
The rapid restructuring of primary care and its affiliated institutions, though seen here as a local or regional phenomenon, reflects the predominance of the global political economy of competition, commoditization, and free marketeering. The effects of these forces extend beyond the reorganization of health care services to include the possible transformation of family practice’s basic culture, moral values and experience. In what has been referred to as the “most dangerous transformation,”26 doctoring as a moral enterprise may be becoming doctoring as an economic enterprise. This transformation is being accomplished by medical directors and administrators who passionately believe in the value of their endeavors. Though the sincerity of such beliefs is not in question, the physicians may fail to recognize the revolutionary shift in the moral values that created those beliefs. As market values become increasingly important, corresponding changes are manifested in the experience, language, sensibility, and emotions of patients and care providers.
Effects on Trust in the Provider-Patient Relationship
Patients’ trust in medical care and in their clinicians may be particularly vulnerable to changes engendered by the new health care environment.7,8,27,28 Trust refers to the expectations that health care providers will assume responsibility without inappropriately deferring to others (control), will perform in a technically proficient manner (competence), and will make their patients’ welfare the highest priority (agency).27 As Gray notes, “The rise of managed care often is seen as undermining the fiduciary ethic and lessening the trustworthiness of care.”8 Trust is critical in maintaining the stability of the provider-patient relationship and provides the glue that holds the whole health care system together. When trust is absent, conflicts and friction increase throughout the system, generating significant social costs to check physician performance and guard against possible adverse outcomes.29 For example, malpractice litigation, “doctor-shopping,” and poorer patient compliance are more likely to stem from provider-patient relationships marked by distrust, suspicion, and poor communication.30-32