BACKGROUND: The competitive managed care marketplace is causing increased restrictiveness in the structure of health plans. The effect of plan restrictiveness on the delivery of primary care is unknown. Our purpose was to examine the association of the organizational and financial restrictiveness of managed care plans with important elements of primary care, the patient-clinician relationship, and patient satisfaction.
METHODS: We conducted a cross-sectional study of 15 member practices of the Ambulatory Sentinel Practice Network selected to represent diverse health care markets. Each practice completed a Managed Care Survey to characterize the degree of organizational and financial restrictiveness for each individual health care plan. A total of 199 managed care plans were characterized. Then, 1475 consecutive outpatients completed a patient survey that included: the Components of Primary Care Instrument as a measure of attributes of primary care; a measure of the amount of inconvenience involved with using the health care plan; and the Medical Outcomes Study Visit Rating Form for assessing patient satisfaction.
RESULTS: Clinicians’ reports of inconvenience were significantly associated (P <.001) with the financial and organizational restrictiveness scores of the plan. There was no association between plan restrictiveness and patient report of multiple aspects of the delivery of primary care or patient satisfaction with the visit.
CONCLUSIONS: Plan restrictiveness is associated with greater perceived hassle for clinicians but not for patients. Plan restrictiveness seems to be creating great pressures for clinicians, but is not affecting patients’ reports of the quality of important attributes of primary care or satisfaction with the visit. Physicians and their staffs appear to be buffering patients from the potentially negative effects of plan restrictiveness.
Managed care has become the predominant approach to health care financing in the United States.1 This explosive growth has been accompanied by an increasingly complex array of types of managed care plans and a growth in the use of restrictions and financial incentives to influence physician practice behavior.2 Contributing to the diversity and complexity of managed care are new incentive systems, strategies to manage patterns of care,3,4 and a shift toward national investor-owned plans. In addition, many practicing physicians are participating in new business relationships, including physician hospital organizations, medical service organizations, and risk-sharing arrangements. The treatment of all managed care plans as a single entity for comparison with fee-for-service plans is no longer adequate to capture the effect of the health care context on the delivery of care or health outcomes.5 A typology of features that represents a plan’s organizational and incentive features would facilitate understanding of what specific aspects affect outcomes of care across the nation.6,7 The Managed Care Survey was developed for use in this study to build on previous work by measuring specific attributes of different managed care plans that may affect both physician and patient outcomes.
Managed care organizations traditionally position primary care clinicians as the cornerstones of their delivery system8; however, the effect of the restrictiveness of managed care plans on the patient-physician relationship and the delivery of important attributes of primary care (as described by the Institute of Medicine9) are poorly understood. A common assumption is that managed care fosters primary care because of its gatekeeper and first-contact functions.8 Since health systems organized around primary care have been shown to have better population-level outcomes,10 one might expect similar results from managed care systems.11-13 Several aspects of the current competitive managed care marketplace, however, do not appear to be conducive to achieving the goals of primary care.14,15 The restrictions on clinicians’ and patients’ choices have raised concerns about the potential detrimental effect of managed care on the patient-physician relationship.16 In addition, the practice of annual re-bidding of managed care contracts can cause a forced disruption in continuity of care17 with detrimental effects on patients.15,18 For these reasons, the Institute of Medicine recommends monitoring the performance of health care systems to assess the adequacy of the delivery of attributes of primary care.9
The restrictions and incentives imposed by managed care organizations that are designed to modify physician practice behavior may inadvertently effect other valued aspects of patient care. The purpose of our study is to evaluate the association of managed care restrictiveness with specific attributes of primary care, visit-based patient satisfaction, and perceived inconvenience (or “hassle”) of using the plan.
Methods
Study Design, Sites, and Sample
A cross-sectional design was used to collect data from 15 member practices of the Ambulatory Sentinel Practice Network (ASPN). ASPN, composed of 752 community-based practicing clinicians, was established in 1982 to conduct practice-based research. Its 122 practices in 34 states have been shown to serve a nationally representative patient population and provide access to health care markets with a wide range of penetration and maturity of managed care.19 We solicited volunteer practice sites and chose 15 US ASPN sites to represent high-, medium-, and low-levels of managed care penetration in both urban and rural areas. Clinician and practice characteristics, including the clinicians’ estimate of the proportion of managed care in the practice, were obtained from the ASPN member database, which is updated annually. All 15 sites that were invited to participate in the study agreed to complete it.