Medical Professionalism under Managed Care: The Pros and Cons of Utilization Review

Health Affairs

Volumn 16, Issue 1, 1997, Pages 106-124

  Schlesinger, Mark J ^a   Gray, Bradford H ^a   Perreira, Krista M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DECISION MAKING; HEALTH INSURANCE; INFORMATION PROCESSING; PROFESSIONAL PRACTICE; STANDARD; UNITED STATES; UTILIZATION REVIEW;

DATA COLLECTION; DECISION MAKING; MANAGED CARE PROGRAMS; PROFESSIONAL AUTONOMY; UNITED STATES; UTILIZATION REVIEW;

EID: 0347419659     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.16.1.106     Document Type: Review

References (58)

1. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Care Plans," Health Affairs (Summer 1995): 99-112; R.J. Blendon et al., "Managed Care: Public and Employer Perspectives," in The Future of American Health Care, vol. 6, ed. R.J. Blendon and M. Brodie (New York: Faulkner and Gray, 1994), 111-128; and B.H. Gray, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Cambridge, Mass.: Harvard University Press, 1991).
2. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Care Plans," Health Affairs (Summer 1995): 99-112; R.J. Blendon et al., "Managed Care: Public and Employer Perspectives," in The Future of American Health Care, vol. 6, ed. R.J. Blendon and M. Brodie (New York: Faulkner and Gray, 1994), 111-128; and B.H. Gray, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Cambridge, Mass.: Harvard University Press, 1991).
3. K. Davis et al., "Choice Matters: Enrollees' Views of Their Health Care Plans," Health Affairs (Summer 1995): 99-112; R.J. Blendon et al., "Managed Care: Public and Employer Perspectives," in The Future of American Health Care, vol. 6, ed. R.J. Blendon and M. Brodie (New York: Faulkner and Gray, 1994), 111-128; and B.H. Gray, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Cambridge, Mass.: Harvard University Press, 1991).
4. D. Emmons and A. Chawla, "Physician Perceptions of the Intrusiveness of Utilization Review," in Socioeconomic Characteristics of Medical Practice (Chicago: American Medical Association, 1991), 3-8; M. Gold et al., Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans, Selected External Research Series, no. 3 (Washington: Physician Payment Review Commission, 1995); E.A. Kerr et al., "Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?" Annals of Internal Medicine 123 (1995): 500-504; and R.G. Frank, T.G. McGuire, and J.P. Newhouse, "Risk Contracts in Managed Mental Health Care," Health Affairs (Fall 1995): 50-64.
5. D. Emmons and A. Chawla, "Physician Perceptions of the Intrusiveness of Utilization Review," in Socioeconomic Characteristics of Medical Practice (Chicago: American Medical Association, 1991), 3-8; M. Gold et al., Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans, Selected External Research Series, no. 3 (Washington: Physician Payment Review Commission, 1995); E.A. Kerr et al., "Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?" Annals of Internal Medicine 123 (1995): 500-504; and R.G. Frank, T.G. McGuire, and J.P. Newhouse, "Risk Contracts in Managed Mental Health Care," Health Affairs (Fall 1995): 50-64.
6. D. Emmons and A. Chawla, "Physician Perceptions of the Intrusiveness of Utilization Review," in Socioeconomic Characteristics of Medical Practice (Chicago: American Medical Association, 1991), 3-8; M. Gold et al., Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans, Selected External Research Series, no. 3 (Washington: Physician Payment Review Commission, 1995); E.A. Kerr et al., "Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?" Annals of Internal Medicine 123 (1995): 500-504; and R.G. Frank, T.G. McGuire, and J.P. Newhouse, "Risk Contracts in Managed Mental Health Care," Health Affairs (Fall 1995): 50-64.
7. D. Emmons and A. Chawla, "Physician Perceptions of the Intrusiveness of Utilization Review," in Socioeconomic Characteristics of Medical Practice (Chicago: American Medical Association, 1991), 3-8; M. Gold et al., Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans, Selected External Research Series, no. 3 (Washington: Physician Payment Review Commission, 1995); E.A. Kerr et al., "Managed Care and Capitation in California: How Do Physicians at Financial Risk Control Their Own Utilization?" Annals of Internal Medicine 123 (1995): 500-504; and R.G. Frank, T.G. McGuire, and J.P. Newhouse, "Risk Contracts in Managed Mental Health Care," Health Affairs (Fall 1995): 50-64.
8. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
9. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
10. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
11. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
12. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
13. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
14. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
15. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
16. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
17. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
18. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
19. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
20. Regarding ethical issues, see, for example, P. Boyle and D. Callahan, "Managed Care in Mental Health: The Ethical Issues," Health Affairs (Fall 1995): 7-22; M.A. Rodwin, "Conflicts in Managed Care," The New England Journal of Medicine 332 (1995): 604-607; E.J. Emanuel and N.N. Dubler, "Preserving the Physician-Patient Relationship in the Era of Managed Care," Journal of the American Medical Association 273 (1995): 323-329; S. Wolf, "Health Care Reform and the Future of Physician Ethics," Hastings Center Report 24, no. 2 (1994): 28-41; E.J. Emanuel and A.S. Brett, "Managed Competition and the Patient-Physician Relationship," The New England Journal of Medicine 329 (1993): 879-882; R. Macklin, Enemies of Patients (New York: Oxford University Press, 1993); and G. Rimler and R. Morrison, "The Ethical Impacts of Managed Care," Journal of Business Ethics 12, no. 6 (1993): 493-501. Regarding attention from the health policy community, out of a total of roughly 430 papers appearing in Health Affairs since 1990, sixty-three were largely devoted to managed care. Only one of these - D. Blumenthal, "The Vital Role of Professionalism in Health Care Reform" (Spring 11994): 252-256 - focused primarily on the question of professional prerogatives under managed care, although several others - Boyle and Callahan, "Managed Care in Mental Health;" and L.C. Baker and J.C. Cantor, "Physician Satisfaction under Managed Care" (Supplement 1993): 258-270 - addressed these issues to some extent. Studies that examine whether managed care techniques alter clinical decision making include A.L. Hillman, "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments, " Annals of Internal Medicine 112 (1990): 891-893; A.N. DeMaria et al., "Managed Care Involvement by Cardiovascular Specialists: Prevalence, Attitudes, and Influence on Pravtice," Journal of the American College of Cardiology 23 (1994): 1245-1253; and J.D. Cartland and B.K. Yudkowsky, "Barriers to Pediatric Referral in Managed Care Systems," Pediatrics 89, no. 2 (1992): 183-192. These studies do not, however, differentiate changes that providers consider within the bounds of professional behavior from those that are perceived as violating professional norms. One survey of young physicians asked respondents in managed and unmanaged settings whether thier clinical autonomy matched their expectations. Baker and Cantor, "Physician Satisfaction under Managed Care." Since expectations themselves may be shaped by the managed care environment, the: responses did not actually provide much evidence about whether managed care was undermining professional norms.
21. K. Grumbach and T. Bodenheimer, "Reins or Fences: A Physician's View of Cost Containment; Health Affairs (Winter 1990): 120-126. This vagueness is found even in the work of sociologists who write with some care about the nature of professionalism. See D. Coburn, "Freidson Then and Now: An Internalist' Critique of Freidson's Past and Present Views of the Medical Profession," International Journal of Health Services 22, no. 3 (1992): 497-512 and F. Hafferty and F. Wolinsky, "Conflicting Characterizations of Professional Dominance," Current Research on Occupations and Professions 6 (1991): 225-249.
22. K. Grumbach and T. Bodenheimer, "Reins or Fences: A Physician's View of Cost Containment; Health Affairs (Winter 1990): 120-126. This vagueness is found even in the work of sociologists who write with some care about the nature of professionalism. See D. Coburn, "Freidson Then and Now: An Internalist' Critique of Freidson's Past and Present Views of the Medical Profession," International Journal of Health Services 22, no. 3 (1992): 497-512 and F. Hafferty and F. Wolinsky, "Conflicting Characterizations of Professional Dominance," Current Research on Occupations and Professions 6 (1991): 225-249.
23. K. Grumbach and T. Bodenheimer, "Reins or Fences: A Physician's View of Cost Containment; Health Affairs (Winter 1990): 120-126. This vagueness is found even in the work of sociologists who write with some care about the nature of professionalism. See D. Coburn, "Freidson Then and Now: An Internalist' Critique of Freidson's Past and Present Views of the Medical Profession," International Journal of Health Services 22, no. 3 (1992): 497-512 and F. Hafferty and F. Wolinsky, "Conflicting Characterizations of Professional Dominance," Current Research on Occupations and Professions 6 (1991): 225-249.
24. D.P. Lipsitt, "Managed Care: A Catalyst for Integrated Medicine," General Hospital Psychiatry 17 (1995): 243-244.
25. E. Freidson, "The Changing Nature of Professional Control," Annual Review of Sociology 10 (1985): 1-20.
26. P. Lee and L. Etheredge, "Clinical Freedom: Two Lessons for the U.K. from U.S. Experience with Privatization of Health Care," The Lancet 337 (1989): 263-265.
27. S.J. O'Connor and J.A. Lanning, "The End of Autonomy? Reflections on the Postprofessional Physician," Health Care Management Review 17, no. 1 (1992). 63-72; A. Linton and D. Peachey, "Guidelines for Medical Practice: The Reasons Why," Canadian Medical Association Journal 143, no. 6 (1990): 485-490; and M. Holoweiko, "What Cookbook Medicine Will Mean for You," Medical Economics (18 December 1989): 118-133.
28. S.J. O'Connor and J.A. Lanning, "The End of Autonomy? Reflections on the Postprofessional Physician," Health Care Management Review 17, no. 1 (1992). 63-72; A. Linton and D. Peachey, "Guidelines for Medical Practice: The Reasons Why," Canadian Medical Association Journal 143, no. 6 (1990): 485-490; and M. Holoweiko, "What Cookbook Medicine Will Mean for You," Medical Economics (18 December 1989): 118-133.
29. S.J. O'Connor and J.A. Lanning, "The End of Autonomy? Reflections on the Postprofessional Physician," Health Care Management Review 17, no. 1 (1992). 63-72; A. Linton and D. Peachey, "Guidelines for Medical Practice: The Reasons Why," Canadian Medical Association Journal 143, no. 6 (1990): 485-490; and M. Holoweiko, "What Cookbook Medicine Will Mean for You," Medical Economics (18 December 1989): 118-133.
30. E. Pellegrino and D. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1989); E. Freidson, "How Dominant Are the Professions?" in The Changing Medical Profession: An International Perspective, ed. F. Hafferty and J. McKinlay (New York: Oxford University Press, 1993), 54-67; and W. Winkenwerder and J. Ball, Transformation of American Health Care: The Role of the Medical Profession," The New England Journal of Mediane 318, no. 5 (1988): 317-319. For sociologists, concerns such as these touch on notions of professional "purity." A. Abbot Status and Status Strain in the Professions," American Journal of Sociology 81 (1981): 819-835.
31. E. Pellegrino and D. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1989); E. Freidson, "How Dominant Are the Professions?" in The Changing Medical Profession: An International Perspective, ed. F. Hafferty and J. McKinlay (New York: Oxford University Press, 1993), 54-67; and W. Winkenwerder and J. Ball, Transformation of American Health Care: The Role of the Medical Profession," The New England Journal of Mediane 318, no. 5 (1988): 317-319. For sociologists, concerns such as these touch on notions of professional "purity." A. Abbot Status and Status Strain in the Professions," American Journal of Sociology 81 (1981): 819-835.
32. E. Pellegrino and D. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1989); E. Freidson, "How Dominant Are the Professions?" in The Changing Medical Profession: An International Perspective, ed. F. Hafferty and J. McKinlay (New York: Oxford University Press, 1993), 54-67; and W. Winkenwerder and J. Ball, Transformation of American Health Care: The Role of the Medical Profession," The New England Journal of Mediane 318, no. 5 (1988): 317-319. For sociologists, concerns such as these touch on notions of professional "purity." A. Abbot Status and Status Strain in the Professions," American Journal of Sociology 81 (1981): 819-835.
33. E. Pellegrino and D. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1989); E. Freidson, "How Dominant Are the Professions?" in The Changing Medical Profession: An International Perspective, ed. F. Hafferty and J. McKinlay (New York: Oxford University Press, 1993), 54-67; and W. Winkenwerder and J. Ball, Transformation of American Health Care: The Role of the Medical Profession," The New England Journal of Mediane 318, no. 5 (1988): 317-319. For sociologists, concerns such as these touch on notions of professional "purity." A. Abbot Status and Status Strain in the Professions," American Journal of Sociology 81 (1981): 819-835.
34. The concept of agency in health care can be traced to Kenneth Arrow's seminal article, "Uncertainty and the Welfare Economics Medical Care," American Economic Review 53, no. 2 (1963): 941-973. This introduced notions, which have subsequently been extended to various aspects of health services, that a good agent (physician) makes the same decisions that the patient would make if that patient were well informed. G. Mooney and M. Ryan, "Agency in Health Care: Getting Beyond First Principles," Journal of Health Economics 12, no. 3 (1993): 125-135. Although the application of this principle has been disputed by some medical ethicists, the general need to deal with information asymmetries is widely recognized. See Pellegrino and Thomasma, For the Patient's Good.
35. The concept of agency in health care can be traced to Kenneth Arrow's seminal article, "Uncertainty and the Welfare Economics Medical Care," American Economic Review 53, no. 2 (1963): 941-973. This introduced notions, which have subsequently been extended to various aspects of health services, that a good agent (physician) makes the same decisions that the patient would make if that patient were well informed. G. Mooney and M. Ryan, "Agency in Health Care: Getting Beyond First Principles," Journal of Health Economics 12, no. 3 (1993): 125-135. Although the application of this principle has been disputed by some medical ethicists, the general need to deal with information asymmetries is widely recognized. See Pellegrino and Thomasma, For the Patient's Good.
36. The concept of agency in health care can be traced to Kenneth Arrow's seminal article, "Uncertainty and the Welfare Economics Medical Care," American Economic Review 53, no. 2 (1963): 941-973. This introduced notions, which have subsequently been extended to various aspects of health services, that a good agent (physician) makes the same decisions that the patient would make if that patient were well informed. G. Mooney and M. Ryan, "Agency in Health Care: Getting Beyond First Principles," Journal of Health Economics 12, no. 3 (1993): 125-135. Although the application of this principle has been disputed by some medical ethicists, the general need to deal with information asymmetries is widely recognized. See Pellegrino and Thomasma, For the Patient's Good.
37. Hafferty and Wolinsky, "Conflicting Characterizations of Professional Dominance;" and P. Caper, "Solving the Medical Care Dilemma," The New England Journal of Medicine 318, no. 23 (1988): 1535-1536. For efforts to police practices through peer review, which had at best a mixed record of success, see R.A. Berenson, "A Physician's View of Managed Care," Health Affairs (Winter 1991): 106-119. These efforts have been further undermined by the recent applications of antitrust law to the profession. W. Curran, "Legal Immunity for Medical Peer Review Programs," The New England Journal of Medicine 320, no. 4 (1989): 233-235.
38. Hafferty and Wolinsky, "Conflicting Characterizations of Professional Dominance;" and P. Caper, "Solving the Medical Care Dilemma," The New England Journal of Medicine 318, no. 23 (1988): 1535-1536. For efforts to police practices through peer review, which had at best a mixed record of success, see R.A. Berenson, "A Physician's View of Managed Care," Health Affairs (Winter 1991): 106-119. These efforts have been further undermined by the recent applications of antitrust law to the profession. W. Curran, "Legal Immunity for Medical Peer Review Programs," The New England Journal of Medicine 320, no. 4 (1989): 233-235.
39. Hafferty and Wolinsky, "Conflicting Characterizations of Professional Dominance;" and P. Caper, "Solving the Medical Care Dilemma," The New England Journal of Medicine 318, no. 23 (1988): 1535-1536. For efforts to police practices through peer review, which had at best a mixed record of success, see R.A. Berenson, "A Physician's View of Managed Care," Health Affairs (Winter 1991): 106-119. These efforts have been further undermined by the recent applications of antitrust law to the profession. W. Curran, "Legal Immunity for Medical Peer Review Programs," The New England Journal of Medicine 320, no. 4 (1989): 233-235.
40. Hafferty and Wolinsky, "Conflicting Characterizations of Professional Dominance;" and P. Caper, "Solving the Medical Care Dilemma," The New England Journal of Medicine 318, no. 23 (1988): 1535-1536. For efforts to police practices through peer review, which had at best a mixed record of success, see R.A. Berenson, "A Physician's View of Managed Care," Health Affairs (Winter 1991): 106-119. These efforts have been further undermined by the recent applications of antitrust law to the profession. W. Curran, "Legal Immunity for Medical Peer Review Programs," The New England Journal of Medicine 320, no. 4 (1989): 233-235.
41. R. Blendon, T. Hyams, and J. Benson, "Bridging the Gap between Expert and Public Views on Health Care Reform," Journal of the American Medical Association 269, no. 19 (1993): 2573-2578.
42. Winkenwerder and Ball, "Transformation of American Health Care," 318.
43. M. Schlesinger, B. Gray, and E. Bradley, "Charity and Community: The Role of Nonprofit Ownership in a Managed Health Care System," Journal of Health Politics, Policy and Law 21, no. 4 (1996): 697-751.
44. Emmons and Chawla, "Physician Perceptions of Intrusiveness."
45. For more details on survey methods and response issues, see Schlesinger et al., "Charity and Community."
46. The respondents reported documentation requirements for four tracer conditions: hysterectomies, back pain, cardiac catheterization, and adolescent depression.
47. Back pain, hip replacement, coronary artery bypass grafts (CABGs), cataract surgery, adolescent depression, and craniotomies.
48. The consistency of these percentages is potentially deceptive: It is not the 1 same third of the industry engaging in all of these practices. There are very low correlations among these different aspects of intrusion; firms that look problematic to clinicians in some of these dimensions are just as likely as any other review firms to look attractive in others.
49. The factors were fitted using a maximum likelihood method. For a copy of the (varimax) rotated factor pattern for the four groupings, contact Mark Schlesinger at Yale University, Department of Epidemiology and Public Health, School of Medicine, 60 College Street, P.O. Box 208034, New Haven, Connecticut 06520-8034.
50. The average respondent to this survey reviews about 50,000 cases a year. This suggests that each firm on average identifies annually between 500 and 1,500 cases of inappropriate care that pose serious risks for patients. Extrapolating to the industry as a whole, review firms apparently identify between 85,000 and 255,000 such problematic cases each year.
51. Preliminary analyses had shown that these agency and accountability practices were unrelated to other characteristics of the review firm, including whether it was national or regional and whether it provided other utilization review services in addition to prior authorization for hospitalization.
52. American Medical Association, Code of Medical Ethics (Chicago: AMA, 1994).
53. Ibid., Opinion 9.031, 130.
54. E. Maynard et al., "American College of Physicians Ethics Manual," Annals of Internal Medicine 117 (1992): 947-960.
55. J.P. Kassirer, "Managed Care and the Morality of the Marketplace," The New England Journal of Medicine 333, no. 1 (1995): 50-52; and M.A. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993).
56. J.P. Kassirer, "Managed Care and the Morality of the Marketplace," The New England Journal of Medicine 333, no. 1 (1995): 50-52; and M.A. Rodwin, Medicine, Money, and Morals: Physicians' Conflicts of Interest (New York: Oxford University Press, 1993).
57. See, for example, Bureau of National Affairs, "New Tennessee Governor Signs Laws on Maternity Stays, 'Gag' Clauses," Managed Care Reporter (22 May 1996): 503; and BNA, "New Jersey Regulators Propose Complete Overhaul of HMO Rules," Managed Care Reporter (12 June 1996): 570.
58. See, for example, Bureau of National Affairs, "New Tennessee Governor Signs Laws on Maternity Stays, 'Gag' Clauses," Managed Care Reporter (22 May 1996): 503; and BNA, "New Jersey Regulators Propose Complete Overhaul of HMO Rules," Managed Care Reporter (12 June 1996): 570.