Increased Production Pressures and Monitoring
Care providers, particularly the more veteran ones, perceive increased pressures to see more patients in less time, while documenting more details of their care (I, F, P, E). Though it is debated whether actual numbers of visits per hour have increased in the observed practices since 5 or 10 years ago, physicians clearly feel that there are marked increases in the amount of administrative and insurance paperwork associated with patient care and in the number of administrative-type visits (I, F, P, E).
In addition, there has been a steady growth in the degree of productivity monitoring (I, F, P, D). Internally, such reports are routinely used as a basis of either actual or projected incentive plans. Externally, “provider profiles” are compiled by insurance groups. Physicians disparage these for having the potential for getting them “deselected” from particular plans (I).
Information Overload
As medical groups and alliances contract with more managed care organizations, practitioners are flooded with staggering amounts of information about each plan’s administrative rules, payment methods, referral networks, drug formularies, and incentive programs (I, F, P, D, E). The situation is further complicated by managed care organizations that create individualized plans for large employers or provider groups, each with its own particular idiosyncrasies (I, P, D, E). Care providers lose track of details as the names, alliances, plans, and rules rapidly change (I, F, P, E). Administrative books from managed care organizations are so numerous they are often ignored, left unopened, or immediately discarded (I, P).
Interference in Clinical Decisions
Care providers in this study were nearly universally concerned about perceived interference in clinical decision making by managed care organizations, insurers, and even their own IPAs (I, F, P). There was a strong sense of a transfer of decision-making power, particularly regarding drugs, laboratory and imaging testing, inpatient stays, and referrals. For example, nearly every managed care organization publishes a medication formulary that lists “preferred” drugs (D), sometimes even specifying preferred pharmacies. Practitioners who choose different drugs from the same class often have to justify their choice, or undertake time-consuming procedures to override the system (I, F, P, D, E).
There was the sentiment among the providers and staff at the study sites of having to jump through “endless managed care hoops” with multiple demands on time and labor (I, F, P, E). This was compounded by the lack of coordination between managed care organizations, each having its own rules and requirements (D). Tremendous energy was being expended in “managing to manage”—from training staff, keeping up with changes, negotiating contracts, providing utilization review and quality assurance, passing audits, and coordinating care of one’s own and others’ patients (I, F, P, D, E). Practitioners felt forced to communicate with vast numbers of bureaucracies: from hospitals, to insurance and managed care companies, to licensing bodies, and local, state, and federal agencies. Particularly for the more veteran physicians, these demands were often seen as “whittling away” time and energy from more productive activities, such as discussions of difficult patients, journal clubs, continuing medical education, or free time (I, F, P).
Adaptations
The medical practices observed in the study appear to have adapted to cope with the demands and pressures of the new health care environment in their area (I, F, P). Some of these changes are difficult to track or corroborate, given the absence of historical documentation. For example, one of the most significant claims made by some of the providers and administrators is that the managed care environment has led to the adoption of cost-effective and evidence-based medical practice (I, F). This movement, though perhaps accelerated by the managed care organizations, likely predated their arrival. Other adaptations have clearer paper trails. For instance, there is ample evidence that to compete in the medical marketplace, physicians and practices at the sites have entered into larger alliances and networks, whether of the IPA or limited liability corporation type (I, F, P, D). These bargain with the insurance companies to avoid discounts on primary care services and provide a steady flow of patients. Physicians at one of the sites even claimed that their decision to sell their practice to a larger network was based on their fear of being unable to compete without such a connection (I).
To cope with the increased business and marketing demands, there has been a specialization of roles within groups, both through the formation of administrative teams and through the hiring or training of insurance specialists who manage the multiple plans, benefits, and referral networks (I, F, P, D, E). The administrative teams at the study sites have tended to include a senior physician (always male and middle-aged), a nurse-manager, and an administrator who is not a care provider. Finally, to avoid the potential loss of a large number of patients if they change insurance plans, groups have begun to accept nearly all plans available in their areas (I, F, P, D, E).