PubMed · 11762086
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W Borges. 2001. A two-front war.. https://pubmed.ncbi.nlm.nih.gov/11762086/
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Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.
Developing more effective approaches to disability prevention has been a longstanding challenge for the workers' compensation system. A major obstacle to this goal has been the lack of communication and interaction between employers and physicians who care for injured workers. From 1995 through 1997, the Washington State Department of Labor and Industries sponsored a major demonstration program, known as the managed care pilot (MCP), to assess the effects of managed care on medical and disability costs, patient satisfaction and employer satisfaction. We developed a telephone survey and administered it to 243 employers as part of the MCP evaluation. Topics covered in this survey include satisfaction with treatment rendered, duration of lost work time, work modifications, and satisfaction with communication received during the employee's recovery period. Employers in the intervention (managed care) condition were more satisfied with the managed care/occupational medicine system than the employers in the comparison group were with the fee-for-service system. MCP employers were satisfied particularly with the frequency and quality of communication received from the health care provider regarding return to work and work modification issues. Improved employer-provider communication may foster early return to work and thereby have a beneficial effect on health and employment outcomes for injured workers.
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