WASHINGTON, Feb. 13 (UPI) -- Specialist physicians across the United States say they have gained more control over patient care following the retreat of managed care insurance in the late 1990s, says a recent study from the Center for Studying Health System Change.
Healthcare analysts say though the findings bode well for consumers wanting more autonomy in their healthcare decisions, there is an economic downside to this trend.
"The significance (of the study) is that it demonstrates from the physician perspective the effective change in what was called managed care, and the actual loosening of restrictions (on physicians) in many cases," J. Lee Hargraves, a senior health researcher at HSC and co-author of the study, told United Press International.
HSC is a healthcare policy-centered think tank funded exclusively by the Robert Wood Johnson Foundation.
Managed care health insurance represents an attempt to control rising healthcare costs by placing restrictions on physicians' authority to provide care. In an effort to contain costs, such plans require patients to first see a primary care physician in order to receive a referral for a specialist. Most plans also limit coverage to a specific list of physicians and hospitals, and require prior approval for high-cost tests and procedures.
Some health plans, however, have more odious practices that were eventually outlawed in many states, such as the withholding of payments to doctors who ordered costly tests or the payment of bonuses to physicians that kept costs low. But consumers and physicians balked at these and other restrictions, and managed care ultimately failed to live up to its promise to contain costs while providing better quality care.
This resulted in movement toward less restrictive preferred provider plans and other insurance models that place fewer restrictions on access to physicians and services.
The HSC study, "Back in the Driver's Seat: Specialists Regaining Autonomy," is based upon an ongoing survey of 12,000 physicians nationwide.
Hargraves and his associates found that as healthcare insurers eased managed care restrictions in response to pressures from physicians and the market, there was a sharp increase in the proportion of specialists who said they have enough control over clinical decisions to effectively meet patient needs.
HSC researchers found that between 1997 and 2001 the proportion of specialists that believe they gained more power over clinical decisions increased from 72.7 percent to 85.7 percent. They also found a marked increase in the proportion of specialists who believe they can maintain their income level while making the best clinical decisions and sustaining long-term relationships with patients.
In contrast, the study found that the views of primary care physicians in these areas changed little over the same period. The study suggests that one explanation for this could be the continued use of capitation -- the payment by insurers to doctors of fixed monthly amounts for care of each patient no matter how many visits -- far more frequently with primary care physicians than with their specialist counterparts.
Tom Miller, director of health policy studies at the libertarian Cato Institute, said the findings are not a real surprise because there has been a fundamental change in the direction of healthcare management over the past five years.
"What we are seeing is a shifting to the next stage of how to deal with healthcare costs," Miller told UPI. "The effort to try and do this through third part supply restrictions fell short and failed to live up to claims of improved quality and more efficient healthcare delivery."
Miller added that while United States is moving toward an insurance system more centered on patient control, the process is not finished and may take 5 to 10 more years to complete.
Betsy McCaughey, an adjunct senior fellow at the conservative Hudson Institute, said care should be taken not to overstate the significance of the HSC study's findings, because both the primary care doctors and specialists surveyed in the report also said they still had too little time to spend with patients.
One prominent healthcare analyst at a liberal-leaning think tank said this complaint simply amounts to physicians overstating their distaste for the controls on their actions that insurers have kept in place.
"Physicians still don't like having any constraints on them," said the analyst. "It is just complaining."
Jon Gabel, vice president of health systems studies at the Health Research and Educational Trust -- an offshoot of the American Hospital Association -- said that some recent and more conclusive studies have shown that the average time that doctors spend with patients has actually increased in recent years.
Gabel also said the loosening of the tight restrictions that managed care plans placed on specialty care and expensive tests is widely considered to be a major reason for the rapid rise of healthcare costs in the United States.
Hargraves also said the cost to employers of providing health insurance to employees has risen in recent years, resulting in higher costs for the insured employees.
"People want more choices and less controls, and what employers are doing is shifting more of the (resulting) cost to them," he said.
He added that projections for the future costs of healthcare in the United States are striking. In 2001, healthcare spending accounted for around 14 percent of the U.S. gross domestic product, up from around 13 percent two years earlier. Recent estimates find healthcare spending will increase to around 17 percent of the GDP by 2011.
The analysts agreed that though people appear to be more satisfied with the freedom they now have in making their healthcare choices, it is unclear whether this has made much difference in the quality of the care they receive.
Despite this, Miller said the overall trend toward more consumer autonomy in healthcare is still a good thing. He added that people who do not want to pay more for more choice have the option of getting cheaper and more restrictive health plans.
"We need an open system where people who want to pay for more freedom can (do) it, and those who do not can pay less for (health coverage with) more insurer control," he said.
One prominent healthcare analyst told UPI consumers will continue to pay more and more for healthcare as long as they demand greater control.
"I don't know that this is necessarily a bad thing," said the analyst. "If people are willing to spend the extra money to have a degree of freedom I think that is fine."
Hargraves said a significant remaining question is whether there is a cost threshold at which consumers are no longer willing to take on more of the financial burden of health insurance in return for freedom from insurer control.
"No one knows what the price is that consumers are willing to pay," he said.
