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

References

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Discussion

We used innovative measures and a unique practice-based laboratory to assess the impact of specific aspects of managed care on the delivery of important attributes of primary care. The findings suggest that the restrictiveness of managed care plans does not affect patients’ perceptions of multiple attributes of primary care or their satisfaction with the visit. However, both financial and organizational restrictiveness were associated with greater clinician-reported hassle. These findings may not conform to the widespread belief by practicing clinicians that plan characteristics affect patients in a direct way,^8,26 and clinicians may be reassured to find that they are able to maintain good primary care relationships with patients amidst the challenges they experience.

Clinician hassle was rated in terms of the time required for insurance-mandated administrative activities generated by the plan (eg, the length and repetition of required forms and written or verbal requirements). Other studies have reported specific physician-reported hassles associated with particular plans.^8,27 Most of the hassles can be attributed to an added administrative burden, such as the need to make phone calls, write letters, and gather information from medical records in response to denial of payment, requests for patient information, or precertification of services.²⁷ Our findings that clinicians reported increased administrative burden with more restrictive plans reinforce the idea by Freberg²⁸ that it is difficult to know whether managed care plans are cost effective or merely add to the hidden cost of administrative overhead. Future studies should investigate the amount of effort required for additional administrative burdens relative to the cost savings of the plan.

The lack of association between patient-perceived hassle and plan restrictiveness indicates that the burdens of plan restrictiveness fall squarely on the shoulders of clinicians and staff. It is also likely that patients who are less concerned about plan restrictions may have self-selected a restrictive plan for cost savings or other perceived benefits. For these patients, the benefits (eg, lower deductibles, coverage of health maintenance visits) may outweigh the disadvantages (eg, restricted freedom of choice, increased personal cost incurred to opt for out-of-plan services).

Concerns have been raised about conflict of interest, the effect of financial incentives on physician behavior, the quality of the patient-physician relationship and decision making, time constraints, and the potential for underservice with managed care systems.^16,26,29-34 Grumbach and colleagues²⁶ found that 57% of physicians surveyed reported that they felt pressure from the managed care organization to limit referrals; 75% felt pressure to see more patients per day; and 17% and 24%, respectively, felt that limiting referrals and seeing more patients per day compromised patient care. In our study, patients in highly restrictive managed care plans did not perceive their physician to be any less of an advocate for their health care than patients in the low- or medium-restrictiveness groups. Thus, this sample of primary care clinicians continued to engage in trusting relationships with their patients despite the potential conflict of interest that could arise from managed care plans’ financial incentives to restrict care.

In our sample of patients, as well as in others,²¹ the CPCI assessed important aspects of primary care with good internal consistency. The instrument’s scale scores have been shown to be associated with patient satisfaction²¹ and delivery of preventive services,³⁵ and have been shown to detect differences in the delivery of primary care to patients who faced forced discontinuity of care and those who remained with their regular physician.¹⁵ The CPCI should be sensitive to many of the potential ill effects of managed care on the patient-physician relationship and delivery of primary care. The lack of association between plan restrictiveness and patient report of primary care is striking, and there is strong evidence that the clinicians and office staff who report being hassled by these restrictions are not allowing those hassles to interfere with their delivery of patient care.

Others²⁶ have evaluated physician satisfaction with specific plan features and physician-rated quality of specific health care plans.³⁶ We asked physicians to objectively report the presence or absence of specific organizational and financial features of each of the managed care plans in their practices. Using the Managed Care Survey to characterize specific organizational and financial aspects of plans is a major advance in being able to test the importance of these features on physician behavior and processes of care and patient outcomes.

Limitations

The main potential threat to the internal validity of the study is patient nonresponse. The nonrespondents were more likely to be men than patients who completed the survey. It is possible that these patients may have been less satisfied with care and may have reported lower scores on the CPCI. However, nonrespondents represent only 10% of those approached, and it is unlikely that the findings of the study would have changed if they had been included. We are also unable to comment on how long a patient had been with their current insurance plan. Length of exposure and actual experience with the features of a plan could potentially affect the association of plan restrictiveness with perceived delivery of primary care. However, consecutive patients were enrolled, which should reduce the likelihood of a selection bias of such a variable.