Loosening Managed Care Rules May Improve Doctor-Patient Relationship

Loosening the "gatekeeping" restrictions of managed care health plans or promoting access to care and continuity of treatment may improve the relationship between patients and their physicians, according to researchers at the Johns Hopkins Bloomberg School of Public Health. Restrictions that require patients to select a primary care physician or obtain authorization for specialty care referrals were associated with a low patient-practitioner relationship rating in a study published in the April 2002 issue of the Journal of General Internal Medicine. 

The findings provide new information on the ways in which managed care influences patients' relationships with their primary care practitioners and may lead to the development of more patient-centered health care programs.

"Across the United States, managed health plans are loosening restrictions on patients' access to specialist care. According to this study, this trend may lead to better patient relationships with their primary care practitioners," says the study’s lead author Christopher Forrest, MD, PhD, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health.

For the study, the Dr. Forrest and his colleagues examined the patient-practitioner relationship, which is characterized by physician empathy towards their patients, communication between doctor and patient, and mutual trust. Data were collected from the 1996-1997 Community Tracking Study Household Survey, which was designed to monitor the effects of health system changes on people living in the United States. The survey asked patients to rate the level of trust they had in their doctor and his or her ability to make decisions in the patient's best interest. Patients rated the level of communication with their doctor and the doctor's competence during examination and treatment. Access to primary care was assessed by asking patients the time it took to travel to a doctor's appointment, the length of time it took to get an appointment, and the length of each office visit. Participants indicated whether their health plan used a provider network, required patients to select a primary care practitioner, or required authorization from primary care providers for specialty referrals, all of which are characteristics of managed care plans.

The results showed that managed care plans that require patients to select a primary care physician or obtain authorization for specialty services were associated with lower ratings of the patient-physician relationship. On the other hand, requiring patients to remain in a provider network had no impact on the relationship scores.

Patients in managed care programs were more likely to have continuity with a specific clinician, which the researchers say is a benefit of managed care over other programs. However, these relationships were less likely to last more than 12 months, which may be due to the fact that participants in managed care plans are often forced to switch health plans.

The study found that shorter office waits, having a specific clinician at a primary care site, and having a longer relationship with a primary practitioner were all associated with a higher rating of the relationship between patients and primary care practitioners. The findings also showed that perceived choice of primary care practitioners was associated with higher patient-physician relationship ratings and moderated the effects of other negative factors.

Dr. Forrest and his colleagues also found that the lack of health insurance is a major impediment to the patient-practitioner relationship. Uninsured patients ranked their relationship with their primary care physician as significantly lower when compared to their insured counterparts.

"These finding add to our understanding of the impact of health system change on patient-centered care and the importance of strengthening the accessibility and continuity of primary care practices. Our findings will be useful to decision-makers interested in improving patients' relationships with their primary care doctors," explains Dr. Forrest.

“Managed Care, Primary Care, and the Patient-Practitioner Relationship” was written by Christopher Forrest, MD, PhD, Leiyu Shi, DrPH, Sarah von Schrader, MA, and Judy Ng, MPH, and appears in the April 15, 2002, edition of the Journal of General Internal Medicine.

Funding was provided by a grant from the Robert Wood Johnson Foundation.