Trust and Trustworthy Care in the Managed Care Era

Health Affairs

Volumn 16, Issue 1, 1997, Pages 34-49

  Gray, Bradford H ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONFLICT OF INTEREST; DOCTOR PATIENT RELATION; ECONOMICS; GOVERNMENT REGULATION; HEALTH CARE AND PUBLIC HEALTH; HEALTH INSURANCE; HUMAN; INFORMATION DISSEMINATION; INTERPERSONAL COMMUNICATION; MEDICAL ETHICS; MEDICAL FEE; NON PROFIT ORGANIZATION; PATIENT ADVOCACY; PROFESSIONAL PATIENT RELATIONSHIP; SOCIAL BEHAVIOR; STANDARD; TRUST; UNITED STATES;

HEALTH CARE AND PUBLIC HEALTH; PROFESSIONAL PATIENT RELATIONSHIP;

CODES OF ETHICS; CONFLICT OF INTEREST; DISCLOSURE; ETHICS, MEDICAL; FEE-FOR-SERVICE PLANS; GOVERNMENT REGULATION; HUMANS; INFORMATION DISSEMINATION; MANAGED CARE PROGRAMS; ORGANIZATIONS, NONPROFIT; PATIENT ADVOCACY; PHYSICIAN-PATIENT RELATIONS; SOCIAL RESPONSIBILITY; TRUST; UNITED STATES;

EID: 0343901149     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.1.34     Document Type: Article

References (56)

1. E. Cassell, "The Changing Concept of the Ideal Physician," Dædalus (Spring 1986): 202.
2. B. Barber, The Logic and Limits of Trust (New Brunswick, N.J.: Rutgers, 1983).
3. E. Freidson, The Profession of Medicine (New York: Dodd, Mead, and Co., 1970).
4. D. Mechanic and M. Schlesinger, "The Impact of Managed Care on Patients' Trust in Medical Care and Their Physicians," Journal of the American Medical Association (5 June 1966): 1693.
5. G. Shaw, The Doctor's Dilemma (New York: Brentanos, 1911), v.
6. M. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993); and A. Relman, "The Future of Medical Practice," Health Affairs (Summer 1983): 18.
7. M. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993); and A. Relman, "The Future of Medical Practice," Health Affairs (Summer 1983): 18.
8. B. Gray, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Cambridge: Harvard University Press, 1991), especially chap. 6 and 8.
9. R. McCleery, One Life - One Physician: Ralph Nader's Study Group Report on the Medical Profession's Performance in Self-Regulation (Washington: Public Affairs Press 1971); and C. Inlander, L. Levin, and E. Weiner, Medicine on Trial: The Appalling Story of Medical Ineptitude and the Arrogance That Overlooks It (New York: Pantheon, 1988), especially chap. 11.
10. R. McCleery, One Life - One Physician: Ralph Nader's Study Group Report on the Medical Profession's Performance in Self-Regulation (Washington: Public Affairs Press 1971); and C. Inlander, L. Levin, and E. Weiner, Medicine on Trial: The Appalling Story of Medical Ineptitude and the Arrogance That Overlooks It (New York: Pantheon, 1988), especially chap. 11.
11. E. Morreim, "Gaming the System: Dodging the Rules, Ruling the Dodgers," Archives of Internal Medicine (March 1991): 443-447; and Gray, The Profit Motive and Patient Care, 309-312.
12. E. Morreim, "Gaming the System: Dodging the Rules, Ruling the Dodgers," Archives of Internal Medicine (March 1991): 443-447; and Gray, The Profit Motive and Patient Care, 309-312.
13. M. Gold et al., Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans (Washington: PPRC, 1995).
14. R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); D. Gianelli, "Bound and Gagged: AMA: Unethical Managed Care Rules Stifle Communication," American Medical News, 5 February 1996, 1, 26; and S. Woolhandler and D. Himmelstein, "Extreme Risk - The New Corporate Proposition for Physicians," The New England Journal of Medicine (21 December 1995): 1706-1707.
15. R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); D. Gianelli, "Bound and Gagged: AMA: Unethical Managed Care Rules Stifle Communication," American Medical News, 5 February 1996, 1, 26; and S. Woolhandler and D. Himmelstein, "Extreme Risk - The New Corporate Proposition for Physicians," The New England Journal of Medicine (21 December 1995): 1706-1707.
16. R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); D. Gianelli, "Bound and Gagged: AMA: Unethical Managed Care Rules Stifle Communication," American Medical News, 5 February 1996, 1, 26; and S. Woolhandler and D. Himmelstein, "Extreme Risk - The New Corporate Proposition for Physicians," The New England Journal of Medicine (21 December 1995): 1706-1707.
17. Freidson, The Profession of Medicine; and Gray, The Profit Motive and Patient Care.
18. Freidson, The Profession of Medicine; and Gray, The Profit Motive and Patient Care.
19. Council on Ethical and Judicial Affairs, Code of Medical Ethics: Current Opinions with Annotations (Chicago: American Medical Association, 1994).
20. Ibid., 99.
21. American Hospital Association, "A Patient's Bill of Rights" (Chicago: AHA, 1973) (Revised 1992).
22. Much state managed care legislation is also framed in terms of patients' rights, often including some version of a right to a free choice of providers and to be free of insurers' interference with physicians' patient care decisions. Whether by design or in effect, such provisions are inimical to managed care, and the legislation is viewed as hostile by advocates of managed care and may limit managed care plans' ability to influence care on behalf of patients.
23. For an early (and approving) conception of the contractual model in medical care, see R. Veatch, "Models for Ethical Medicine in a Revolutionary Age," Hastings Center Report (June 1972): 5-7.
24. Patients' rights pertain to informed consent, access to specialty care, and confidentiality; clear information about coverage, how coverage decisions are made and how they can be appealed, and about the costs of coverage; a reasonable choice of providers; and information about incentives and restrictions that might influence providers' practice patterns. Patients' responsibilities include pursuing healthy lifestyles, becoming knowledgeable about their health plans, participating actively in decisions about their health care, and cooperating fully on mutually accepted courses of treatment.
25. There are surprising parallels between the patients' rights section of the NCQA accreditation standards and the AMA's original 1847 code of ethics. Both discuss patients' rights and responsibilities, including the responsibilities to disclose pertinent information to the physician and not to bother the physician with minor matters and irrelevant information.
26. "New Association Announces Name and Philosophy of Care," Press release, 26 February 1996, American Association of Health Plans, Washington, D.C.
27. M. Pauly and M. Redisch, "The Not-for-Profit Hospital as a Physicians' Cooperative," American Economic Review 63, no. 1 (1973): 87-99.
28. G. Majone, "Professionalism and Nonprofit Organizations," Journal of Health Politics, Policy and Law (Winter 1984): 639-659.
29. H. Hansmann, "The Role of Nonprofit Enterprise," Yale Law Journal 89, no. 5 (1980): 835-901.
30. J. Alexander, M. Morrisey, and S. Shortell, "Physician Participation in the Administration and Governance of System and Freestanding Hospitals: A Comparison by Type of Ownership;" and R. Musacchio et al., "Hospital Ownership and the Practice of Medicine: Evidence from the Physician's Perspective," in For-Profit Enterprise in Health Care, ed. B. Gray (Washington: National Academy Press, 1986).
31. J. Alexander, M. Morrisey, and S. Shortell, "Physician Participation in the Administration and Governance of System and Freestanding Hospitals: A Comparison by Type of Ownership;" and R. Musacchio et al., "Hospital Ownership and the Practice of Medicine: Evidence from the Physician's Perspective," in For-Profit Enterprise in Health Care, ed. B. Gray (Washington: National Academy Press, 1986).
32. M. Schlesinger et al., "The Privatization of Health Care and Physicians' Perceptions of Access to Hospital Services," The Milbank Quarterly 65, no. 1 (1987): 33.
33. M. Pauly, A. Hillman, and J. Kerstein, "Managing Physician Incentives in Managed Care: The Role of For-Profit Ownership," Medical Care (November 1990): 1013-1024.
34. Using data reported by HMOs to state insurance regulators, Mark Schlesinger and I found that between 1987 and 1991, the ten largest for-profit HMOs in the country spent, on average, 86.2 percent of revenues on medical services, whereas the ten largest nonprofits spent 92.2 percent.
35. The disenrollment numbers are for 1993 and come from the Physician Payment Review Commission, based on data from the Health Care Financing Administration. The complaint data come from the Network Design Group and were reported in G. Anders, "Humana Gets Some of the Poorest Scores in Study of HMO Medicare Complaints," The Wall Street Journal, 31 January 1995, B5.
36. The InterStudy Competitive Edge (Excelsior, Minn.: InterStudy, Summer 1996).
37. A. Ginsberg and A. Buchholtz, "Converting to For-Profit Status: Corporate Responsiveness to Radical Change," Academy of Management Journal 33, no. 3 (1990): 445-477; and B. Gray and M. Schlesinger, "HMOs and the Changing Control of American Health Care" (Unpublished paper).
38. A. Ginsberg and A. Buchholtz, "Converting to For-Profit Status: Corporate Responsiveness to Radical Change," Academy of Management Journal 33, no. 3 (1990): 445-477; and B. Gray and M. Schlesinger, "HMOs and the Changing Control of American Health Care" (Unpublished paper).
39. Nonprofits also may provide more public goods and community benefits, though only sketchy evidence exists. See M. Schlesinger, B. Gray, and E. Bradley, "Charity and Compassion: The Role of Nonprofit Ownership in a Managed Health Care System," Journal of Health Politics, Policy and Law (Winter 1996): 697-751.
40. "For-Profit HMOs Push Service, but Nonprofits Get Higher Rating trom GTE," Managed Care Reporter (15 May 1996): 478; and "Rating the HMOs," U.S. News and World Report (2 September 1996): 54.
41. "For-Profit HMOs Push Service, but Nonprofits Get Higher Rating trom GTE," Managed Care Reporter (15 May 1996): 478; and "Rating the HMOs," U.S. News and World Report (2 September 1996): 54.
42. These include policies regarding capital, tax exemptions, and the oversight of nonprofit conversions to for-profit status.
43. W. Mariner, "Business vs. Medical Ethics: Conflicting Standards for Managed Care," Journal of Law, Medicine, and Ethics (Fall 1995): 236-246.
44. M. Schlesinger, B. Gray, and K. Perreira, "Medical Professionalism under Managed Care: The Pros and Cons of Utilization Review," Health Affairs (January/February 1997): 106-124.
45. J. Robinson and L. Casalino, "The Growth of Medical Groups Paid through Capitation in California," The New England Journal of Medicine (21 December 1995): 1684-1687.
46. H. Darling, "What Information Would Purchasers Like to See?" and D. McNeill and B. Bradley, "Employers' Need for Clinical Data in Managing Health Care Costs," in Measuring Clinical Care: A Guide for Physician Executives, ed. S. Schoenbaum (Tampa: American College of Physician Executives, 1996).
47. H. Darling, "What Information Would Purchasers Like to See?" and D. McNeill and B. Bradley, "Employers' Need for Clinical Data in Managing Health Care Costs," in Measuring Clinical Care: A Guide for Physician Executives, ed. S. Schoenbaum (Tampa: American College of Physician Executives, 1996).
48. National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS) 2.5; and Standards for Accreditation (Washington: NCQA, 1995) The new HEDIS 3.0 will be implemented in 1997. See also J.K. Iglehart, "The National Committee for Quality Assurance," The New England Journal of Medicine (26 September 1996): 995-999.
49. National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS) 2.5; and Standards for Accreditation (Washington: NCQA, 1995) The new HEDIS 3.0 will be implemented in 1997. See also J.K. Iglehart, "The National Committee for Quality Assurance," The New England Journal of Medicine (26 September 1996): 995-999.
50. National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS) 2.5; and Standards for Accreditation (Washington: NCQA, 1995) The new HEDIS 3.0 will be implemented in 1997. See also J.K. Iglehart, "The National Committee for Quality Assurance," The New England Journal of Medicine (26 September 1996): 995-999.
51. Consumers' Guide to Health Plans (Washington: Washington Consumers' Checkbook, 1995 and 1996).
52. Helen Darling, manager, Healthcare Strategy and Programs, Xerox Corporation personal communication, September 1996.
53. M.L. Berk and A.C. Monheit, "The Concentration of Health Expenditures: An Update," Health Affairs (Winter 1992): 145-149.
54. Monitoring plan-specific patterns of disenrollment and adopting performance measures that can detect unusual types or levels of dissatisfaction among high users, or potentially high users, of services in an HMO could help to reduce the incentive to encourage the disenrollment of high-cost patients. This is becoming increasingly feasible.
55. NCQA, Health Plan Performance Data: Are Purchasers Providing the Results to Consumers? (Washington: NCQA, 1995).
56. I have in mind the kind of report that Consumer Reports did in 1996 regarding HMOs and the community-specific health magazines that have developed in many cities. Also, the NCQA began making HMO accreditation summaries available to the public in 1996.