Does Managed Care Restrictiveness Affect the Perceived Quality of Primary Care? A Report from ASPN

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Original Research

Does Managed Care Restrictiveness Affect the Perceived Quality of Primary Care? A Report from ASPN

J Fam Pract. 1999 October;48(10):762-768

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Analyses

Data from the Managed Care Survey and the patient survey were linked by a unique identifier on the basis of site and site-specific health care plan. Patient surveys that could not be linked (eg, because of a missing plan identifier or because the plan was not rated on the Managed Care Survey) were included in the descriptive statistics of the study sample, but are excluded from the analyses involving the managed care features. Descriptive statistics of the sites, clinicians, and plan features are calculated. We used chi-square tests to compare the data available from the nonresponders with the data from the responders to assess bias.

We used the Pearson correlation to test the association of the plans’ financial and organizational restrictiveness scores with the clinicians’ reports of hassle. The association of the managed care plan restrictiveness scores with each of the CPCI scale scores, patient satisfaction with the visit, and patient perceived hassle was tested with multilevel modeling techniques using hierarchical linear regression software.²⁴ Multilevel modeling is an analysis technique that accounts for the nested structural context of the data. Two potential confounding variables, patient age and health status, were included as covariates in these analyses.

Results

All 15 sites returned a completed Managed Care Survey. Practice characteristics are displayed in Table 1. One fourth of the practices had experienced a recent professional merger and one third had undergone a recent purchase or buyout. The average number of managed care plans in each practice ranged from 1 to 25, with an average of 13.3 plans. The average proportion of patients in a managed care plan per site was 51% (range = 21% to 100%). The 41 clinicians participating in the study are characterized in Table 2. The vast majority of clinicians had MD degrees, and 66% were men. On average, clinicians spent 90% of their time on patient care.

The patient response rate was also excellent. Of the 1922 patients approached, 1839 (96%) agreed to complete the patient survey. One hundred and six patients returned a blank survey and represent passive refusers. Of the 1733 patients returning a survey at least partially completed, 1503 were established patients, and 230 were new patients. Twenty-eight established patients did not see their regular physician, and that physician was not a member of the office they were visiting that day. These patients were excluded, bringing the final patient sample size to 1475.

Patient characteristics are reported in Table 3. The majority of patients were women, and health status, on average, was good. Most patients (84%) saw their regular physician, approximately half had a well-care visit within the past 2 years, and approximately one fourth were treated for a serious illness within the past 2 years. Fifty-nine percent of established patients had some type of managed care insurance. Standard Medicare and Medicaid insurance accounted for 21% of patients, and only 11% were categorized as having traditional commercial insurance. Established patients who declined to complete the patient survey (n = 41) were similar in average age and type of insurance but were more likely to be men than the patients who completed the survey.

Table 1, Table 4 displays the frequency of the different managed care features measured by the Managed Care Survey. Laboratory services, preauthorization, specialty networks, and site of service were features of more than 50% of the 199 managed care plans characterized. Physicians rated plans with a restrictive feature as generating greater hassle on average than plans without restrictive features. The 2 exceptions to this trend were plans with point-of-service and withhold features.

We investigated the association of managed care plan restrictiveness with each of the CPCI scale scores and patient satisfaction with the visit. Of the 870 patients with a type of managed care insurance, 786 patients had complete data for this analysis. For ease of interpretation, the managed care restrictiveness scores were divided into low (27%), medium (46%), and high (27%).²⁵ This categorization of the restrictiveness scores has 3 advantages: interpretation of 3 group means versus a b coefficient is easier; a nonlinear association is readily determined; and the distributions of the outcome measure for the high and low groups can be shown to be nonoverlapping. If no statistically significant difference is found between these 2 distinctly different extreme groups, this can be taken as evidence for not rejecting the null hypothesis of no association.

As indicated in Table 5, the mean of the different CPCI, hassle, and patient satisfaction scores were very similar across each level of managed care plan financial restrictiveness. Similarly, organizational restrictiveness was not significantly associated with any of the CPCI scale scores, patient report of hassle, or the satisfaction scores. These analyses were adjusted for patient age and health status and the nested effect of the data.