BACKGROUND: In the last decade managed care has become the major form of health care delivery in the United States. Though some persons believe that managed care is the salvation of family practice, critics claim that it threatens many of the core concepts of primary care. We systematically examined 5 US family practices, to provide a microanalysis of the current situation, particularly from the viewpoint of the care providers.
METHODS: During 1997 and 1998, case studies were conducted at 5 sites using long interviews, focus groups, and extensive participant-observation of provider-patient and provider-staff interactions. Participants included 54 health care providers, 18 administrators, 45 nurses or nursing assistants, and 30 ancillary staff at the sites.
RESULTS: We found dominant themes of rapid change, disruption, increased demands, interference in clinical decision making, and adaptation. Health care providers have the perception of being in the midst of a revolution with disruptions of key relationships and local knowledge. The clinicians in the study feel a loss of certainty, control, and autonomy.
CONCLUSIONS: There appears to be a rampant ideologic competition occurring between business and beneficence for the moral sensibilities of family medicine providers. This is potentially hazardous to feelings of trust in the provider-patient relationship. The focus of much of the warring has been on managed care, though many of today’s problems either predated its development or were peripheral to it. More empirical and observational studies are needed to document the fundamental changes taking place in today’s health care environment.
Managed care continues to grow rapidly in the United States, both in terms of absolute numbers and its effect on the health care system. Though managed care originated here in the early 1900s as pre-paid group practices, real growth did not accelerate until the passage of the federal Health Maintenance Organization (HMO) Act in 1973. Total enrollment in HMOs rose 58% between 1993 and 1996, and by 1997, half the population and nearly three quarters of insured working Americans were in some type of managed care plan.1-2
Though proponents see managed care as the savior of family practice, critics claim that it threatens many of the discipline’s core concepts. There is particular concern for the preservation of the physician-patient relationship.3-5 Elements of managed care’s very structure and organization are claimed to be the source of conflicts and ethical dilemmas for providers,6-8 constraining or otherwise negatively affecting the provider-patient relationship.9 What was traditionally (and perhaps mythically) considered a dyadic relationship between the clinician and the health care consumer has been potentially jeopardized by a new triangular interaction: the patient–provider–managed care/health insurance bureaucracy.
To date, such allegations are primarily opinion; there is an absence of sound empirical or observational data to support or refute these charges. This is a particularly serious void given the growing importance of the subject, the rapid changes in the field, and the current ideologic nature of the free-market health care debate. The objective of our research was to provide a systematic microanalysis of the state of American family practice, giving particular attention to the effects on health care providers.
Methods
Sites and Subjects
Case studies were conducted at 5 family practice groups in Massachusetts and Pennsylvania, the states ranked second and eighth, respectively, in terms of HMO market penetration with 42% and 21% of their residents enrolled.1 To increase generalizability, efforts were made to provide a balanced mix of urban, suburban, and rural practices serving diverse patient populations Table 1. Site preference was given to practices affiliated with independent practice associations (IPAs), since these are the dominant form of HMO in the United States.1 Each practice contracted with several managed care companies (range = 12 - 50), either directly or through their IPAs. Such contracts accounted for approximately 50% (range = 45% - 63%) of total billings.
The number of physicians at the sites varied from 1.5 to 9 full-time equivalents (FTEs). All physicians were board-certified family physicians, except one general internist-pediatrician, and 2 family practice residents. Mid-level providers or their trainees (nurse practitioners and physician assistants) were present at all sites. All practices were owned at the onset of the research by vertically integrated, not-for-profit health care organizations, except one, which was an independent not-for-profit community health center. Care providers were salaried, though individual contracts contained varying incentive plans.
Data Collection*
We conducted pilot studies in 1996 and 1997 to gain familiarity with the issues, focus research efforts, refine the data collection tools, and test the feasibility of the study.
Data collection at the 5 practices was conducted between June 1997 and March 1998. Each case study used multiple qualitative methods including participant-observation,10-11 focus groups,12-14 long interviews,15-16 and the analysis of key texts.17 These techniques were chosen because of their ability to identify key issues, record actual behavior in its context, elucidate lived experience, generate unexpected insights, and bring to light the shared meanings, cultural categories, and mental world of informants.