Bioethics Study Shows Managed Care's Effect on Doctor-Patient Relationships

A study conducted by the Medical College of Wisconsin's Center for the Study of Bioethics presents data that quantify the negative impact that managed care has had on the doctor-patient relationship in Wisconsin. The study was recently published in the Cambridge Quarterly of Healthcare Ethics .

Robyn S. Shapiro, JD, Director and Professor of Bioethics, is the author of the study, in which 2,711 Wisconsin physicians were surveyed between 1995 and 1996. Her goal was to analyze the prevalence and types of managed care arrangements in the state, and find out what kind of impact these arrangements have on physicians and their relationships with patients.

The report was the first to offer scientific evidence that managed care has impaired the doctor-patient relationship.

"Over the past several years, there have been frequent anecdotal reports about managed care's effects on health care delivery, but little data had been collected or analyzed," Shapiro said. "While some of our findings regarding the impact of managed care were predictable -- for example, half of our respondents indicated that they have changed their clinical behavior since participating in managed care -- the degree to which managed care has changed physicians' practices was somewhat surprising.

"For example, 75% of our respondents said that managed care organizations influenced their ability to order diagnostic tests at least occasionally. In addition, we were somewhat surprised about responses that addressed appropriate redress for these changes. About 65% of the physicians said that authorization denials for tests or treatment were 'never' or only 'occasionally' reversed through the use of internal complaint resolution mechanisms."

Before the advent of managed care, the physician's obligations were owed almost exclusively to the patient. The study shows that physicians are growing more concerned with their obligations to the managed care organization -- so much so that their clinical behavior has been altered:

• Physicians now have a greater likelihood to discharge patients prior to full recovery.
• Physicians now have a greater reluctance to make treatment decisions regardless of cost.
• Physicians now have a greater reluctance to refer patients to specialists or emergency departments.
• Physicians now have a greater reluctance to spend a comfortable amount of time with patients.

To conduct the study, the Center for Bioethics obtained a list of all the physicians licensed in Wisconsin in 1995, and sent each of them an 8-page survey. The survey questions were broken down into four categories:

1. History, prevalence and nature of managed care arrangements in the respondent's practices.
2. Objective changes in the respondents' clinical behavior and compensation attributable to managed care.
3. A subjective review of the respondents' levels of satisfaction with their clinical autonomy; with their managed care patients' access to various medical services; and their stress levels.
4. A collection of demographic data.

Managed care comprised at least 21% of most respondents' practices, and approximately one-fourth responded that managed care represented more than 50% of their medical practice.

Shapiro said she hoped the report would be helpful at both the state and national levels as policymakers consider patient protection legislation and regulations.

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