With these sales and mergers have come disruptions in the manner of doing business, in referral patterns, and in strategic alliances (I, F, P, E, D). Ramifications have ranged from the redefinition of the “target community,” the “enemy,” and the “common good,” to reconsideration of the worth of redundant facilities and personnel, and the value of educating students and residents (I, F, P, D). At a practice sold to a for-profit hospital group, the changes have been more fundamental: reordering of priorities to increase earnings, movement from local community and religious leadership to distant corporate management, and layoffs of affiliated staff and physicians (I, F, P, D). After years of allowing practices in their network to run at a deficit, the new owners brought with them a new business ethos. As one administrator described: “These guys are serious—if you don’t make a profit you’re out.” (I)
As networks, alliances, managed care organizations, health plans, hospitals, and medical groups arise, merge, and disappear, providers are experiencing discontinuities in many of their key professional relationships (I, F, P, E, D). For example, as pressures to trim expenses accelerate in the more competitive health care environment, some nurses have been replaced with lower-salaried nursing assistants. Physician-hospital relationships have been disrupted as the affiliated community hospitals are closed or converted to nonacute patient wards, as happened in 4 of the 5 study sites. Even the relationships with HMOs and managed care companies have been fractured as these corporations merge and change names and personnel (I, F, P, D).
Physician-Patient Relationships
One of the most fundamental changes noted is the disruption of long-term relationships between patients and care providers (I, F, P, D, E). At the study sites, the choice of health care plan or benefits is largely vested with employers or government agencies, rather than with consumers. As both providers and patients noted, insurance choices can shift either when the patient changes jobs or when employers (or patients) choose “cheaper” plans during yearly bidding (I, E, P). These shifts often necessitate finding a primary care provider who is enrolled in the new plan. Providers felt that this situation results in the splintering of the continuity of care and the impression of “endless” numbers of new patients (I, F, P). It is rare to open up a patient chart in these practices without coming across duplicated records from at least one previous practitioner (E, P). Though some exceptional patients choose to stick with their providers under any circumstances, both parties seem to be aware that those bonds may be severed at any time (I, F, P, E). Some providers even report a change in their attitudes toward “investing” in patients, since they do not see the same kind of continuity and mutual commitment as existed previously (I). Nonetheless, despite such pronouncements, it should be noted that in nearly all observed care provider-patient encounters, the care providers appeared sincerely engaged in the care of their patients (P, E).
Clinicians at the sites report increased patient demands, “pushiness,” and suspicion (I, F). In physician-patient discussions over such issues as referrals and imaging tests, they report new concerns among patients who fear that their physicians are “holding out on them” to increase profits or to “save the money for themselves or the insurance company” (I, F). Patient concerns are perceived to be shifting from receiving “unnecessary” health care to receiving “too little” care.
Physican-Physician Relationships
Among the family practice physicians interviewed, there is a strong sense that, as one physician stated, “Managed care has made relationships more adversarial…not just between doctors and patients, but also between doctors and other doctors.” There are confrontations over money and monetary concerns—negotiating subcapitations, dividing the capitation pie, and limiting utilization—or over the responsibility for getting authorizations (I, F, P).
Physician Roles
The role of the family physician at the practice sites appears to be undergoing transformation from the traditional one of gatekeeper (I, F, P, D, E; Table 2. Under fee-for-service arrangements, though the physician may have had a financial interest in encouraging the use of health services, providers incurred no financial risk from their medical decisions (I, D). Today, as billing for fee-for-service dwindles, primary care physicians have increasingly become subcontractors to managed care organizations (I, F, P, D). In addition, they are assuming new roles as stakeholders or co-insurers in certain capitated plans whereby a varying degree of their income is “at risk” (I, F, P, D).
In an environment in which the provider’s choice of tests, referrals, and treatments may directly influence their group’s and their own fiscal health, there is a definite temptation to limit services or to use different strategies for capitated as opposed to fee-for-service patients (I, P). The influence of insurance status on clinical decision making is an inflammatory topic (I, F ,P). As one physician noted, “Morally and legally we are in a bad place if we start treating differently.” The interviewed providers vehemently deny such practices and little of this type of behavior was observed (I, F, P, E). The normalized value, whether stated or implicit, is “the right care at the right place at the right time,” irrespective of other factors (I, P). Nonetheless, a few minor inequities were noted (I, P). For example, several physicians admitted to protesting more if patients in their group’s risk pool appeared at the emergency department for what they considered unjustified indications, compared with when the cost was shouldered by the patient or a third party (I). Some physicians were more hesitant to order expensive tests for their capitated patients (ie, spiral computerized axial tomography scans for renal lithiasis or endoscopy for suspected peptic ulcer disease) than they were for their “free-spending indemnity patients, past and present” (I, P). Elaborate mechanisms of utilization review were also in place for patients in total risk contracts; no such mechanisms were present for other patient panels (I, P, D, E).