POWER RELATIONS IN HEALTH CARE: THE DEGRADATION OF
PHYSICIAN STATUS IN THE ERA OF MANAGED CARE AND ITS
EFFECTS ON THE DOCTOR PATIENT RELATIONSHIP
Herminio G. Miranda
B.A., Castleton State College, 1996
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
1999 by Herminio G. Miranda
All rights reserved.
This thesis for the Master of Arts
Herminio G. Miranda
has been approved
Miranda, Herminio G. (M.A., Sociology)
Power Relations in Health Care: the Degradation of Physician Status in the Era of
Managed Care and its Effects on the Doctor Patient Relationship
Thesis directed by Associate Professor Candan Duran-Aydintug
The introduction of managed care, specifically Health Maintenance Organizations
(HMO), into health care has brought a dramatic shift in the control of the social
institution of medicine. Physicians are no longer the principal figure within medical
care, since their role has been severely limited by restrictions imposed by HMOs.
This study focuses on the physicians loss of power and prestige in addition to HMOs
effect on the doctor/patient relationship. This study seeks to explore reasons why
physicians would allow their profession to be manipulated into a system used for
corporate profit maximization. This study also inquires how physicians perceive their
position in the social context after the incorporation of managed care.
The study is a qualitative, inductive study that uses in-depth interviewing and
an interview guideline consisting of fifty-three questions. Not all the questions were
asked to the respondents and not all of the responses were instituted into the final
analysis due to inconsistencies and irregularities in the responses. The responding
physicians were, however, allowed to speak on any one question for as long as they
desired. The sample consisted of twenty-one physicians with different specialties;
The majority of the respondents, though, had primary care patients.
The findings indicated that physicians have lost any ability to function
independently and implement or modify existing medical policy, all powers doctors
enjoyed before the advent of managed care. The respondents also displayed a sense
of bewilderment as they had to endure denunciation by HMOs and patients. Growing
conflicts of interest are forcing medical professionals to favor monetary gain while
placing the patients wellbeing in jeopardy, the respondents were not willing to admit
this but were disillusioned that their patients saw them as adversarial. The findings
also suggested that older physicians were more likely to disagree openly with the
HMOs and risked being terminated for their beliefs. Younger physicians were more
likely to either portray a sense of appeasement toward HMO or had no attachments
that might endanger their careers.
This abstract accurately represents the content of the candidates thesis. I recommend
This research is dedicated to Dr. Alicia Maria Davila MD, whose devotion to
integrity should be a lesson for us all.
The author would like to thank the physicians who shared their expertise and
opinions on the state of health care. A very special thanks to Dr. Duran Aydintug,
whose facilitation and direction were invaluable. A deeply felt appreciation goes to
Agnes Covas, my mom, for her encouragement and belief in my abilities.
1. INTRODUCTION........................................... 1
2. REVIEW OF THE LITERATURE................................... 4
Division in Literature..................................... 4
Recent History of Managed Care............................. 5
The Role of Managed Care................................... 6
Opposition to Managed Care................................. 7
Efficacy of Managed Care.................................. 13
Capitated Payment Systems................................. 20
The Doctor Patient Relationship......................... 24
Purpose of Study.......................................... 32
3. METHODOLOGY............................................... 38
5. CONCLUSIONS AND LIMITATIONS..................... 62
A. INTERVIEW GUIDLINE AND CONSENT FORM.............. 67
3.1 Breakdown of specialist by area of concentration in the sample population 36
3.2 Age characteristics of the sample population.......................... 37
3.3 Year Graduation from Medical School of sample population............... 38
There was a time when those who fell ill could simply make an appointment
with a physician within a reasonable time. The visit with the physician was an
opportunity to discuss a wide range of issues concerning health and other life
endeavors. The patient knew that this was an important relationship because the
physician was ensuring soundness of body as well as the mind and was treating the
problem to the best of his/her ability. The physician was a trusted and admired
member of the community who had taken an oath that required him or her to hold the
interest of the patient above everything else.
Times have changed, physicians no longer have the ability to dictate
treatment. They no longer have the time to discuss the most basic health problems
with patients, and their capacity to adhere to the Hippocratic Oath has been severely
limited by restrictions. The incorporation of managed care has transmogrified health
care into prioritizing a different system of values that disallow the most basic
mechanisms of the doctor/patient relationship from positively working. The
introduction of Health Maintenance Organizations (HMO) has gravely confined the
function of the physician and has allowed for the conception of ulterior motives to
surface in order to permit this value system to coerce them into adhering to it.
The principal virtue within the new system is the profit motive, the
appeasement of financial obligations and expectations are the dominant factor in
determining a course of treatment for any patient with an HMO. With many parent
HMO companies being publicly held, vital interest lies with the satisfaction of the
stockholder. This dilemma amplifies the growing disdain felt by physicians, not
because they seek to reap profits from patients, rather it severely limits their ability to
control the state of medicine. This translates into the physicians deteriorating status
and prestige in their credibility and their capability to have any significant input in the
implementation of new medical policy. With a physicians loss of power, health care
represents a fundamental shift in the control of capital within one of the greatest
This shift in omnipotence has virtually destroyed the foundation of the
doctor/patient relationship, and has created a sense of antagonism by the public
towards physicians. Yet certain physicians, specifically those who have been
practicing over three decades, denounce HMOs as immoral and decadent to all that is
fundamental to a healer. Even though those physicians with such conviction swear to
press on, all indication seems to indicate that this would be to little too late for them
to reverse the course of action taken by HMOs. The profit motive that has attracted
capitalists in direct conflict with caregivers, or cost containment in contrast to saving
lives and has positioned itself to dictate medical policy for decades to come. During
this process, the role of the physicians has also shifted. Their responsibilities no
longer bare the patients health at any cost; any patient treatment places a tremendous
cost to the physician in terms of financial loss and professional survival.
The indoctrination of health care into the capitalist power structure should not
come as a surprise. The portrayal of physicians had always been that of a highly
specialized labor that deserved high recognition and compensation. Even though they
are subject to loss of autonomy and increased restrictions by HMOs, Primary Care
Physicians are now being compensated with capitated payment systems. Capitation is
the practice of paying physicians in advance by compensating them a fix amount per
member per month. At the surface, this seems to fall within the sphere of any
corporate organizational setting. Physicians responsibilities have diminished and so
have their compensation. However, with the profit motive looming through all
platforms of health care, physicians are now incised with monetary interest to provide
as little care as possible. Therefore, it is essential to discover what is the motivation
for physicians to follow unreasonable restrictions that impede their ability to provide
decent medical care.
This study seeks to explore the conflict of interest that has perpetuated a shift
of power from physicians to HMO and their parent companies. The incorporation of
the capitalist power structure within health care has demonstrated a disregard for
patient health. Despite this, this study does not seek to vilify free enterprise but to
discover what effects this has brought to the state of health care in the United States.
As physicians attitudes are deciphered in this study, the potency of the profit motive
is also analyzed as an indoctrinating tool in the redefining of the doctor/patient
relationship. The shift of capital translates beyond pecuniary commodities into the
power to dictate life and death. This study attempts to captivate the physicians need
to transcend through human wants by exposing their temptations.
REVIEW OF THE LITERATURE
Division in Literature
Since its conception several decades ago, managed care has been increasingly
dividing pundits and experts over its benefits to patients. For over a decade, the
validity of the emerging health care system has come under considerable attack or
praise depending on the position of the analyst. Those who support or criticize
managed care have investigated every conceivable point of disputation. Managed
care can be divided into several subdivisions in order to analyze its efficacy. These
subdivisions consist of traditional managed care indicators such as cost containment,
patient autonomy, accessibility, physician compensation, and risk adjustment.
However, for purposes vital to this study a more complex set of indicators must be
established in order to categorize efficacy. These include qualitative variances of
established ethical guidelines by physicians, opportunities for conflicts of interest in
contacts available to physicians, and most importantly, the level of concern the
physicians have for the well-being of the patients.
It is imperative to understand how decisive physicians are in regards to the
organizational structure of these plans. This, however, is a daunting task. The
majority of the literature referred to in this section is not directly conducive to this
study. The reality facing this analysis is that attitudes of physicians toward capitated
payment systems, in terms of how it affects their relationship with the patient have
not been researched in the past. Therefore, the majority of the literature will be that
of a secondary nature and will provide a framework for research.
Recent History of Managed Care
Prepaid group practice has been in place since 1910 (Phase II consulting,
1998). Dr. Thomas Curran and Dr. James Yocum contracted their services to a
Tacoma Washington lumber company. They agreed to provide medical services for
$.50 per member per month. By 1917, opposition to prepaid plans begins as a county
medical service bureau was organized by physicians to limit competition by prepaid
plans (Phase II consulting, 1998). Managed care, however, remained a relatively
small part of the American Health care system until the early 1970s.
In 1973, Congress passed the Federal Health Maintenance Organization Act
(HMO) that gave managed care the ability to apply for grants and loans. These funds
became available for any HMO who is in a start up phase or in the process of service
area expansion. What propelled HMO to national recognition, however, was the
dual choice provision. This was a federal mandate that required employers with
more than 25 employees that offered indemnity coverage or traditional insurance, to
offer two or more federally qualified HMOs (Kongstvedt, 1997). Before this
mandate, there was thirty-seven active HMOs in the United States. In 1970 the total
U.S. National expenditure was at $85 billion and rising, which led President Nixon to
advocate for the HMO Act in order to cut Medicare spending and to stimulate
industry growth. By 1975, HMOs grew to 183 in 32 states with 297 in planning
stages (Phase II consulting, 1998). Although HMOs were experiencing steady
growth throughout the 1980s they remained secondary to the more traditional
indemnity and fee-for-service plans. It has only been within the last decade that
managed care has become the mainstream framework of health plans across the
The Role of Managed Care
The basis for the creation of managed care is to control cost through the
implementation of several procedures. The source of contention on whether managed
care actually controls cost and provides adequate care is unclear. The management
process offered by many managed care consultants reflects a conservative business
plan that, according to physicians might, present some ethical problems. Milliman &
Robertson Consulting is the premier transition group that helps traditional health care
organizations to transform into managed care. This group has developed a six-phase
transition process that incorporates new physician decision procedures. The first of
these procedures is concerned with identifying clinical quality and efficiency
improvement opportunities. This agendum involves separating the administrative
task from the medical responsibilities in order to apply cost cutting models. The
latter procedures of the transition process are intended to induce the physicians
decision to cost compliance. Developing medical guidelines, educating physicians,
providing performance feedback, and creating incentives for physician are intended to
be a check system by which health plan administrators can determine whether
physicians are being compliant with cost cutting procedures (Milliman & Robertson,
1995). With these established guidelines, the response from the medical community
has been mixed. Many, for profit managed care, plans have developed lucrative
incentives for physicians that have led to the reformulation of medical ethics. This,
however, will be further reviewed below under capitated payment systems. Yet,
there has also been strong opposition to the inception of managed care from the
Opposition to Managed Care
As reasons for this opposition are reviewed from sources written, edited, and
published by the medical establishment, it is essential to maintain an objective
skepticism. For it is not the intent of this literature review to side with these medical
journals, but to have an instrument of analysis when coding the collected data.
Managed care is being incorporated due to rising health care expenditures. In a series
of continuing education articles Christopher C. Colenda and Fredrick T. Sherman
(1988), state that many physicians:
Feel that the downside of managed care has been the disruption of
values that have been central to the delivery of health care in the
United States. These concerns include: intrusion of case management
services into medical decision making that is central to the doctor-
patient relationship, limiting choice and access to hospitals and
health care providers, restriction of benefits, and the considerable
controversy over the definition of, and who decides what is
medical necessary care (1998 p.57).
These disputatious issues have created factions of proponents and critics of managed
care. Definitive research on the validity of managed care is nonexistent as every
credible piece of literature that supports the efficacy of managed care has another
piece of literature debunking its claims. Yet, for the purposes of this research, it is
essential to put forth literature from the physicians perspective since they compose
In 1995 The Council on Ethical and Judicial Affairs, the ethical arm of the
American Medical Association, published a report on the ethical issues of managed
care. In this report, they accused managed care plans of only recruiting doctors who
accept lower reimbursements or have a history of practicing lower cost care. In
addition, they restated that denying access to medical specialists is a common practice
among these plans and that they also restrict physicians by making certain treatments
unavailable (Council on Ethical Judicial Affairs, AMA, 1995). These criticisms,
however, are common not only among members of the medical establishment but also
among the populace. This report, which will be introduced in detail under capitated
payment systems, denounces financial incentives offered to physicians but do not
scom doctors for accepting them.
The report also claims that managed care compromises the quality and
integrity of the doctor-patient relationship by reducing the quality of care and creating
conflict that might jeopardize the physicians obligation to the patient (Council on
Ethical Judicial Affairs, AMA, 1995). Therefore, the Council on Ethical Judicial
Affairs (CEJA) suggested that under such a system, physicians cannot act as patient
advocates, because the model does not allow for complete doctor autonomy. If this
truly is the case, a legitimate question arises, why are so many young doctors flocking
to managed care and capitation? Alternatively, have our expectations of the doctor -
patient relationship changed? The council reports that ethical concerns brought up by
managed care are unique in that they categorize patients in terms of plan flexibility.
Physicians are expected to balance the interests of patients with the interests of other
patients, but this ethical infraction has been prevalent since the beginning of
institutionalized care. Traditional fee-for-service plans were largely dictated by
physicians and hospital administrators, causing a tremendous disparity among those
who had insurance and those who did not.
A power shift has occurred as those who have the authority to dictate
managed care regulate the influx of capital into health care. The hysteria of
increasing expenditures allowed for the traditional view of health care to change as
corporate executives, business managers, and insurance bureaucrats were invited in
not because of their knowledge of clinical care but their expertise in developing a
positive bottom line (Himmelstien and Woolhandler, 1900). These new forces in
medicine soon discovered that potential for profitability, as David U. Himmelstien
and Steffie Woolhander write:
The recent conversion of health care from the public service to private
industry has brought those who profit from providing health care into
conflict with industries for whom health care is a cost of production.
This inter-corporate conflict powerfully shapes health care policy.
It has caused the rapid proliferation of HMOs and other forms of
prospective payment which establishes incentives for cost containment
but allow health institutions to remain profitable, and has hastened
the decline of physician dominance in both health policy and clinical
decision making (p. 15).
Therefore, this shift in power status allows for the speculation for ulterior motives
rather than the physicians loss of the advocacy role. For decades, physicians enjoyed
the most prestigious occupation according to the National Opinion on Prestige of
Occupation Score reference. These scores have, over time, remained consistent. The
correlation between scores from 1947 and 1963 NORC surveys was for all practical
purposes, exact 0.99 (Gilbert and Kahl 1993, p.41.).
Recently, physicians have been experiencing a backlash as the populations
frustration toward managed care has grown. The frustration from patients derives
from a overt satisfaction with the quality of managed care, especially HMOs. This, in
turn could be caused by a number of different reasons, but the obvious simplicity of
the situation cannot be escaped. Although physicians claim that the structure of the
American health care system works against free interaction, patients pass the blame to
managed care as well as to physicians. In a set of open question to physicians, Louisa
Kasdon Sidell (1998) asked doctors about specific issues concerning
physician/patient interaction. When she asked physicians where the most amount of
pressure comes from, the most prevailing sentiment was the rush burden placed upon
them by capitation, as one doctor put it:
Some health plans are now rewarding doctors by paying them more
money for the number of patients they see. So that they get paid more
for the 40th patient through the 60th than the first 39. If we doctors get
caught up in that nonsense, then we should reexamine why we became
doctors in the first place (Kasdon-Sidell, 1998 p.97).
This physician is speaking of capitation and its requirements of per member per
month (PMPM), which leads to a cluster of complex issues discussed further below.
Yet, for the purposes of patient dissatisfaction, the feeling of being short-changed is a
real one. This fact leads to Kasodn-Sidells next question, Do you think patients
worry that this pressure compromises the treatment you receive?, to which a doctor
Sometimes patients confuse the doctor with the insurance company
and get mad at me. They think that all doctors and insurance companies
are part of a huge conspiracy out to deny them care and take their money
(Kasdon-Sidell, 1998 p.98).
Consequently, there is a sentiment among doctors that patients are not looking at
them through the same lense of respect they once enjoyed. Although there is a large
population of medical professionals adamantly against managed care, this
phenomenon by and large is a residual effect of physicians accepting managed care
and financial incentives for the implementation of cost cutting measures.
When physicians accept such measures and then publicly announce their
distaste for managed care, the public grows serious mistrust for the medical
community. Managed care tactics allow for such sentiment by only contracting with
physician networks who accept aggressively micromanage utilization, and reduce test
and procedures for financial incentives. This is evident in the management of care for
senior citizens with hypertension. In their study, Webster and Feinglass found that
elderly patients in managed care plans are three times more likely to be placed in a
skilled nursing facility than a rehabilitation hospital after suffering a stroke (Webster
and Feinglass 1997). Even though skilled nursing facilities might provide adequate
care, they do not serve in the best interest of the patient since the patient is not
exposed to consistent physician evaluation. Given this, the question are physicians
responsible in providing the best possible care, or are they bound by contractual
obligations, becomes more meningful.
This uncertainly has led many people to question the very efficacy of
managed care. Research on the subject is very mixed; the consensus is that managed
care does save money, but if not managed in the interest of the patient then the quality
of care is diminished. This, leads to more questions that will not be answered by this
study, such as determining the real motives behind health care corporations. Stephen
Wiggins, CEO of Oxford Health Plans had a 1996 annual compensation of
$29,061,599.00, his Executive Vice Presidents compensation exceeded $11,000,000.
Wilson Taylor, CEO of Cigna Corporation salary was 11,568,410.00 and Joseph
Sebastianellis, CEO of Aetna Health Care, 1996 salary was $7,394,506.00 (Health
Administration Responsibility Project, 1997). These salaries are indicative of how
health care has transformed itself into an autonomous industry. These powerful
executive positions, although common in other industries were unheard of in health
care only two decades ago. Health care, formerly a supplement producer of other
business activities, is now an icon of capitalist production. In addition, health care, as
in other business sectors of capitalist production, is disinterested in what particular
product is being produced. (Himmelstien and Woolhandler, 1990). Therefore, it is
logical to assume that the implementation of the corporate structure in health care is
both unavoidable and only natural in a capitalist system.
Efficacy of Managed Care
As mentioned above, the validity behind managed care studies presently
depends on the author or researcher. The indicators that go into such deliberations
are usually quite partisan depending on what one considers most vital. Money, for
many of these corporations, is the single determining factor in managed care efficacy.
Therefore, the first determinant is whether managed care controls health care
expenditures. A vast majority of economists will say it does, since the model
contains guidelines for physicians to follow that ensures cost conscious decisions. A
researcher can not pronounce managed care a marvel of economics simply because it
cuts utilization of hospital services. However, this is precisely what many studies on
the efficiency of managed care do. By not taking into account other factors, such as
the potential ethical and operational conflicts that are inherent to managed care, any
position paper becomes nothing short of an editorial.
Economist Reed Neil Olsen (1993) published a study that incorporated
aggregate measures into cost analysis by taking into account such objective measures
as the death rate in particular areas. Olsen contended that the death rate reflected the
impact of Health Maintenance Organizations (HMO) on health care cost. This was
assessed using two different formulations, first, per capita hospital expenditures and
per capita personal health care expenditures (Olsen, 1993). By using these two
measures, Olsen was able to determine that HMOs have no significant impact on
health and reduced expenditures over time. He also stated that the during the critical
transition period from fee-for-service to managed care cost might actually rise, but
this would be temporary (Olsen, 1993). Therefore, he concluded that HMOs were, in
fact, a positive force within the American health care system. However, there are
some serious flaws in his analysis. Olsen stated that the personal health care
expenditure measure was much more accurate in determining cost, yet by his own
limitations he declares that these data are only available from the period of 1980 to
1982 (Olsen, 1993). It would be virtually impossible to determine HMO efficacy in
such a period of time that is also well before the institutionalization of managed care.
His secondary measure of hospital expenditure was collected in the period of 1982 to
1988; any managed care data set collected before 1990 will provide a poor sample
simply due to the newness of the health care model.
Olsen also refutes any negative intentions by HMO corporations, he continued
HMOs have an incentive to economize on providing services since
given the patients fixed periodic payment, doing so increases HMO
profits. In fact, HMOs may actually have an incentive to underprovide
services with resultant decreases in their enrollees health. The HMO
incentive to reduce services below efficient levels is mitigated by three
factors. First, since HMOs are contractually obligated to provide medical
services, they have an incentive to provide cost-effective preventative
care to its enrollees. Second, HMOs have evolved in an increasingly
competitive health care market. Finally HMOs and their physicians
are still subject to malpractice litigation (Olsen, 1993, p.3).
The mediating factors Olsen described are vague and ambiguous. Actually, many
times HMO contracts are complicated and difficult to understand by the lay person.
Also, employer plans are often non-negotiable and are structured to benefit the
employer instead of the enrollee. Malpractice litigation is solely indented for
physician transgressions, not HMO operational errors. According to Jane Bryant
Quinn (1997), HMOs have evaded being successfully litigated due to quirks in the
law. As elderly patients become more susceptible to denial, HMOs have been sued
under the Employer Retirement Income Security Act of 1974, which includes health
plans. Yet, traditionally litigation of this manner is only handled at the state level
where patients lack this type of protection. This provision makes federal litigation
against HMOs extremely difficult to pursue (Quinn, 1997).
The most pertinent indicator of managed care efficacy needs to be centered on
the patients health. Does patients health rest upon the effectiveness of the health
plan? How should these health plans be evaluated? In November 1997, the
American Heart Association had their 70th Scientific Sessions Meetings. In a session
entitled In-Hospital Mortality is Higher in AMI Patients Enrolled in an HMO, Paul
N. Casale, MD spoke of the medical communitys concern that HMOs restrictive
guidelines may adversely affect clinical outcomes. Dr. Casale analyzed 3,999
patients with acute myocardial infarction (AMI), 1034 were HMO patients while
2965 were fee-for-service (FFS) patients. This study found that HMO patients fared
worse than FFS patients; mortality rates for those HMO patients were higher than
FFS patients. Dr, Casale also found, that FFS patients were more likely to have
specific procedures done. FFS patients were more likely to undergo cardiac
catheterization and percutaneous transluminal coronary angioplasty than HMO
patients. Based on these findings, Dr. Casale determined that enrolment in an HMO is
an independent predictor of hospital mortality in those patients with AMI (Ince, MD,
In another study entitled, Differences in 4-Year Health Outcomes for Elderly
and Poor, Chronically 111 Patients Treated in HMO and Fee-For-Service Systems, the
authors sought to compare physical and mental health outcomes of chronically ill
adults, including elderly and poor subgroups, treated in health maintenance
organizations and fee-for-service systems (Ware, Bayless, Rodgers, Kosinski,
Tarlov, 1996, p. 1040). This study was composed of a four-year observational study
of 2235 patients with hypertension non-insulin-dependent diabetes mellitus
(NIDDM), recent acute myocardial infraction, congestive heart failure, and
depressive disorder. The patients sampled were from HMO and FFS systems in the
period of 1986 to 1990. Patients were sampled in three separate metropolitan areas
(Ware, Bayless, Rodgers, Kosinski, Tarlov, 1996).
The results varied; when comparing HMOs to FFS systems physical and
mental health outcomes only differed among subgroups of the population. These
subgroups consisted of differences in age and poverty; for older patients declines in
health were more common among those enrolled in HMO plans because they did not
provide adequate services. Mental health among older patients was considered lower
among those enrolled in HMO plans in two of the three sites. The authors concluded
that physical health among the young, well to do people does not depend on health
system, the elderly and poor are more at risk in HMO systems than in FFS systems
(Ware, Bayless, Rodgers, Kosinski, Tarlov, 1996).
In other words, the medical outcome study suggests, that the most vulnerable
in American society are at risk when relying on HMOs for medical care. However,
this is a difficult assumption to state since the authors do not specify why HMOs are
less likely to provide adequate health care for the old and disenfranchised. This study
does not interpret specific formulations in the managed care model as the source of
the inconsistency. It would, none the less be a logical assumption to suggest that this
study does not take a for or against stance toward managed care. Since this study
derives from the medical community, it must take precautions on policy implications.
Managed care has allowed increased profits as budgets diminish; therefore,
reimbursement is not in the hands of physicians. The power of administrative control
has been taken from physicians by those who manage and own the massive
concentrations of capital now needed to practice medicine (Himmelstein and
Woolhandler, 1990 p 18).
In order to avoid misconceptions, Rubin and colleagues conducted a study to
determine how patients rate different types of practices. This study also applied the
size of the practice as a determining factor in the ratings of distinct health care
systems. Their sample consisted of adult patients (n = 17,671) who had just had an
office visit to 376 participating physicians. They asked the patients to rate their visit
from excellent to poor in different health care systems in a crosstabulation of FFS and
HMO health care systems with Multispecialty Groups (MSG) and Single Specialty
(SOLO) practices. HMOs and FFS systems are primary as to the functionality of a
certain practice, while MSG and SOLO imply whether a practice has multiple
physicians or only one doctor. Their results showed that patients who went to SOLO
practitioners were more likely to rate their visits as excellent, no matter under what
system the physician was operating under. Patients who went to large HMO offices
were most likely to rate their office visits as poor. In fact, out of all the possible
practice types researched, MSG HMOs were rated the worst (Rubin, 1993).
What about the physicians ratings, namely, do they rate HMO systems as poor
as do the patients? Steven J. Borowsky and colleagues set out to answer these
questions by asking physicians (n=249) to rate health care plans that encompassed
HMOs and FFS. In this study, the authors chose physicians from the plans published
list of health care professionals. These physicians were asked to asses the plan in
which they belonged in the categories of overall quality, health plan practices,
allocated physician time, utilization management, quality of primary care, and other
less significant characteristics. The results showed an overall dissatisfaction with all
plans currently used, although those physicians who assessed the HMO plan were the
most dissatisfied. Fifty-five percent of the physicians who agreed in some fashion
when asked I am never asked to put cost containment ahead of good patient care
belonged to non-HMO network model plans while forty-four percent who disagreed
belonged to an HMO network plan (Borowsky, Davis, Goertz, and Lurie, 1997). In
addition, only thirty percent of physicians agreed that either of the plans provided
timely feed back explaining why authorizations are denied. Yet, when asked, do
authorization policies of the plan disrupt the doctor patient relationship only thirty
eight percent of physicians agreed (Borowsky, Davis, Goertz, and Lurie, 1997). Such
inconsistencies present a problem in determining the effect managed care has on the
doctor patient relationship, the analysis of data in this study might provide avenues
to solve these problems.
In another study by Halm, Causino, and Blumenthal (1997), physicians who
provide their services to HMO as well as FFS, were asked to rate both these plans in
terms of their role. In the HMO plans, physicians were relied upon as gatekeepers,
a position that consolidates care and reduces any excess expenses by emphasizing
prevention. Prevention, however, is based on deciding what treatment the patience
needs with an emphasis on cost cutting methods. The information requested
measured physicians attitudes on twenty-one different aspects of care, including the
added administrative work in managed care. The authors used questionnaires that
were mailed to physicians in order to gather data on the functionality and quality of
the two plans; they achieved a 61% response rate. This percentage becomes crucial
in interpreting their findings since they declared that (70%) of the respondents rated
gatekeeping as good or better than fee-for-service (Halm, Causino, & Blumenthal,
In three significant areas, the authors found that physicians felt gatekeeping
had a negative effect on the physician patient relationship on the appropriate use of
hospitalization, and on the ability to order test and procedures. The authors also
noted that favorable gatekeeping attitudes were primarily amongst young physicians
(Halm, Causino, & Blumenthal, 1997). Therefore the record is not clear as to what
caused these contradictory attitudes to emerge; one could go as far as to assume that
those physicians who did not respond did so out of disgust or apathy toward managed
care. This would indicate a significant response bias and produce questions on the
validity of the findings. The prevalent discourse within health care is that physicians
are not content with managed care. Only an in-depth qualitative analysis would allow
these discrepancies to be addressed.
Capitated Payment Systems
Capitation simply means prepayment for services on a per member per month
(PMPM) basis. This means that SOLO practitioners or MSG groups are paid an
established amount dictated by a contract. Depending on the number of patients
enrolled, physicians are paid the same amount for that number whether his or her
patients are ill or healthy. In a particular example by Thomas S. Bodenheimer and
Kevin Grumbach; if one thousand people belong to a certain plan that pays their
primary care physicians (PCP) by capitation say at ten dollars PMPM, this, would
mean that these PCPs will get one lump sum of ten thousand dollars every month. If
the one thousand people are healthy and do not need office visits, then the PCPs will
be paid the ten thousand without doing much work. However, if the one thousand
people suddenly become ill and the PCPs are forced to work continuously with out
time off, they would still only be paid the ten thousand dollars per month
(Bodenheimer & Grumbach, 1996).
For decades, insurers were complaining about the loss money they had to
endure due to physicians over-utilizing expensive procedures, tests, and other forms
of medical techniques. Under FFS health plans, more money is t paid out than the
cost of premiums ill patients pay, therefore, putting insurance companies at risk to
loose money. Under capitation, insurers transfer the risk to providers by paying the
physician a set amount for a particular patient. This means, once the patient becomes
ill, it is the physician who must bare the cost of treatment. HMOs want to restrict as
much service as possible in order to decrease the PCPs demand for higher capitation
payments (Bodenheimer & Grumbach, 1996).
Capitation rates are not the sole cost cutting device used by HMOs. Plans can
determine utilization, adopt requirements for precertification, or have the power to
withhold supplemental income against shortages. Therefore, capitation alone is not
enough to implement cost conscious models. Several other factors are involved
(Berwick, 1996). Although capitation can and does affect decisions by physicians, it
also produces a conflict of incentives that undermines doctors autonomy. Such a
system that forces doctors to be at a financial risk every time they order a specific
procedure creates an ethical dilemma for the doctor but not for the corporate manager
Of course, capitation is not exclusively allocated for PCPs. Occasionally
specialist are paid in are by such systems. With the proliferation of HMOs, the
number of specialist being compensated by capitation is sure to rise. Usually,
physicians compensated by capitation set aside a referral fund or a risk pool, collected
through a specified percentage of their incomes. These funds are primarily for
payment of specialist and ancillary procedures. Even though if the fund still hits
money by the end of the year or month, the PCPs will usually divide it up as bonuses.
PCPs who practice alone might have to divide it up with their corresponding hospital
depending on contract specifications. In some plans, these funds may just be
sufficient to cover overhead cost and in others, it might represent a significant part of
the physicians compensation (Bodenheimer & Grumbach, 1996).
Risk adjustments determine capitation rates, which currently are represented
by demographics. However, Fowles and colleagues published a study considering
health status when setting capitation rates. Their results were not obvious when
setting capitation rates for simulated enrollee groups compared to the larger
We compared the predictive accuracy of alternative risk-adjusted
capitation rates across simulated enrollee groups: low risk, average risk,
and high risk groups.......For example the demographic model
yielded predicted rates that were 7.9 % above actual expenditures for
the low risk groups. This finding means that across the 20 low-risk
groups, the average predicted expenditures were nearly 8% higher
than the actual expenditures in year 2. The 5.2% for the high risk
groups indicates that a capitation rate based on demographics would
result in rates that were 5.2% below the actual expenditures (Fowles,
Weiner, Knutson, Fowler, Tucker, and Ireland, 1996, p.6).
Using the statistical demographic model, the authors concluded that if the general
capitation adjustment method were correlated to the demographic model, the rate
would be set almost eight percent higher. Although, a five percent increase in
capitation rates would be necessary in order to adjust rates according to demographics
for high risk groups. (Fowles, Weiner, Knutson, Fowler, Tucker, and Ireland, 1996,
p.6). The latter of this equation is troublesome, because it forces physicians to take
on added risk. This population is more likely to need medical treatment, and rates are
not always accurate to their needs.
The less adequate the risk adjustment the more likely the physician is to rely
on incentive to make ends meet. Therefore, physicians have begun joining collective
physician groups to better utilize capitated funds. The more people who join HMOs
compensate their physicians.through capitation, the more difficult it becomes for
physicians to demand higher rates. This is especially true for populations who are at
higher risk for medical problems and use emergency rooms for primary care. This is
troublesome for physicians who have both capitated patients and FFS patients,
because one catastrophic case on the capitated side which liquefies available
resources, forces them to take from the FFS side of their practice (Terry, 1994).
Capitation, however, has been integrated into the medical establishment by
approval from physicians. Every physician who is compensated by capitation signed
a contract, where this was indicated; Therefore, physicians objections to such
payment systems after the fact are somewhat overstated. Some supporters of
capitation such as medical editorialist, Jim Montage explains that physicians should
join large independent physicians organizations in order to limit risk and share
referral funds. Montage quotes David Ogden, a consultant at Milliman and
Robertson, who states that different compensation methods sometimes cause friction
among physicians, especially between primary care physicians and specialists
The Doctor Patient Relationship
There is an inherent danger with physicians having to allocate resources from
FFS patients to those under capitation. Physicians are likely to have an incentive to
treat capitated patients as second class patients compared to FFS patients who are not
going to have any sort of limitations on treatment or time. This reconstructs the
physician role, which in turn places doubt on the motive of the physician. As the
institution of health care changes, physicians are also expected to incorporate these
changes at any expense. The shift in power and status has changed the image of
physicians from healers of humanity to mere employees selling services for the profit
of others. The medical community is well aware of the effect this transformation has
had on the doctor patient relationship.
The doctor patient relationship is in transformation due to the corporate
structure that is intrinsic within HMO management. U.S. Healthcare, a 2.4 million
member of HMO includes in their contract with HMO stipulations that physician
cannot disseminate any information that may prove detrimental to the confidence of
the enrollees. U.S. Healthcare spends 74% of its revenue on medical care while one
million a day is allocated for profits (Woolhandler and Himmelstien, 1995). This
information being public knowledge and physicians inability to portray their
objection to corporate health care have contributed to the decay of trust patients
share with physicians. As of 1995, seventy four percent of Independent Practice
Associations (IPA) and fifty percent of HMOs calculated physician payments on
measures of utilization and cost. This has caused HMO managers to come out and
say that such a large incentive compromises the quality of care (Woolhandler and
Woolhandler and David U. Himmelstein continued to say:
This system pressures doctors to exploit patients trust for financial
gain. We can influence patients choices among health plans, and
we know their health status and care seeking behavior the optimal
data for risk selection. Steering low-cost Medicare to HMOs and sick
one to FFS care means windfall profits from the former to the latter
(Woolhandler and Himmelstien, 1995, p.2).
With such motives prevalent within the medical community it is difficult not to
foresee the deterioration of the traditional doctor patient relationship. The ethical
dilemma facing physicians is a daunting one, should they strive to what Menikoff has
written; should they be cost blind and risk unemployment, situations unheard of for
physicians? Medical professionals have two very different schools of thought from
which to choose. Should they advance the goal of cost control and become wealthy
practicing such techniques or should they act as patient advocates and oppose cost
cutting initiatives imposed by managed care? If the latter is chosen, is the risk of
being shun from what seems to be the future of health care worth it? However, in
such tumultuous times physicians are trapped in transition zones where confusion in
the future of health care leaves them open for malpractice (Menikoff, 1997).
Ethical standards may help preserve the doctor patient relationship, since it
denounces any motivation that might serve against the interest of the patient. A
physician is bound to do all they can do for the patient without bias or hindrance.
Beneficence and autonomy are principals that physicians must abide to if they are
going to practice medicine. These basic concepts are supported by the American
Medical Association (AMA) and are not likely to change soon (Menikoff, 1997).
Incentives brought on by capitation do in fact create a conflict of interest: The
question is, will physicians allow such conflict to cloud their clinical decisions and let
it corrode the doctor patient relationship? Intensity of incentives is another factor in
the quality of medical care; the range of services, the potential for monetary loss and
gain, and the bonus model all affect the level of intensity. To limit intensity,
physicians have proposed limiting the amount of financial incentives and only open
capitation agreements to large physician conglomerates. To further limit negative
incentives, physicians could instal ethical principals that would safeguard the doctor
- patient relationship by limiting risk or gain pitfalls that might force someone to
question a physicians ethics (Pearson, Sabin, and Emanuel, 1998).
Conflict among patients is another chief concern to the maintenance of the
doctor -patient relationship. Patients are forced into competition with each other by
the limit of the availability of specific procedures which causes bedside rationing.
According to the Council on Ethical and Judicial Affairs in the AMA, such
techniques are not part of the traditional physician role. The council contends that
such competing concerns not only undermine the physicians moral obligations but
also place the patient in direct competition with organizational need dictated by health
care plans (CEJA, AMA, 1995). Managed care is funded by a specified amount that
has been allocated from an operating budget, therefore it perpetuates rationing and
cost cutting techniques that is common with sustaining a healthy bottom line. The
dilemma among physicians is that these techniques could be successfully managed
under the correct conditions. Cutting cost for the sake of the stockholder and
executive incomes does not meet these correct conditions. If rationing were
introduced in a fair and impartial manner, instead of by health plan, then, perhaps,
criticism of managed care would not be so abundant.
The physicians gatekeeper role has been developed to ensure restricted access
to advanced medical care. This includes referrals, diagnostic tests, and other
expensive procedures, from which the physician is offered incentives to avoid.
Consequently, the patients needs are in sharp contrast with the organizational needs
of the health plan (CEJA, AMA, 1995). This produces a new question among
physicians, do they have any obligation toward the health plan to keep cost low, or is
this a blatant infraction of medical ethics? It is also logical to assume that physicians
are not used to filling such a subservient role. This may contribute to strong feelings
of animosity that the physician takes out on the patient.
Physicians have their own plan to correct rationing problems; it consists of
establishing a medical advisory board within every hospital that would have powers
in deciding managed care policy. This produces obvious questions: Are they out to
rectify the dilemma the patient experiences or their own? Do they seek to cure the
health care system of injustices or are they trying to regain a status they once held?
Health care is an institution, which traditionally has been seen by Americans as
headed by physicians. This image has been perpetuated by television, movies and
other forms of popular culture (Emanuel and Dubler, 1995). Recently, however,
Americans have begun seeing the medical institution as controlled by managed care
corporations. This evident by the strong demands constituents have made placed on
their elected representatives to draft some form of patient bill of rights.
The doctor patient relationship is based on communication in which the
inhabited freedom of patients to discuss their concerns openly has been the comer
stone of the doctor patient relationship for decades. Before the advent of managed
care, personable skills proved to be invaluable to a physicians practice. These skills,
known as core communication skills, include several parameters that are not only
essential for this relationship but also expected by patients. According to Epstein and
Beckman, there are a set of communication skills that provide successful encounters
between patients and doctors: Eliciting the patients perspective on illness,
recognizing and responding to the patients emotions, and coming to agreement on
the nature of the problem and its treatment (Epstien & Beckman 1994, p.172).
These skills have allowed physicians to gain the trust and respect that is so vital in
Emanuel and Dubler (1995) categorized the fundamental elements of the ideal
physician- patient relationship into what they termed the six Cs. The first of these
categories is choice, choice of practice type, choice of primary care physician, or
specialist, and treatment alternatives. The second is competence, this is an overall
assurance that the physician is accredited and is in fact a knowledgeable practitioner
of medicine. The next category is communication, communication is essential for the
physician to understand the patients symptoms and the effect of health problem to
the patients personal life. Compassion is also, according to Emanuel and Neveloff-
Dubler is a vital part of the doctor-patient relationship (Emanuel and Neveloff-
Are physicians patient advocates or do they advocate self-gratification,
prestige and personal accumulation? Whose interests are they to hold dear when
making life and death decisions? Continuity is the following category, this of course
is non-apparent among managed care since many patients change occupations that
force them to keep changing health plans. The last category is (no) conflict of interest
which implies the physicians should not have misplaced incentives offered to them.
(Emanuel and Neveloff-Dubler, 1995). All of the six Cs are vital to the doctor-patient
relationship, even though all six are in severe jeopardy to be removed by managed
care. Yet, these abstract ideals must protrude through managed care policy if the
doctor patient relationship is to be restored.
Sociological research on why certain physicians are empathetic and others are
not has been limited in the past. In order to fully understand the phenomenon one
must look past any financial incentives that might influence physicians attitudes. In
a landmark study, Carmel and Glick sought to discover whether personality traits,
such as empathy and compassion, were enhanced or inhibited by social-
organizational factors (Carmel & Gilck, 1996). The authors contended that the
potentiality of compassionate traits were largely due the socialization during
childhood adolescence and were clear signs of stable personality traits. These virtues,
the authors further stated, were positively correlated to self-esteem and pro-social
attitudes (Carmel & Gilck, 1996). Once the authors illustrated that these traits were
developed before physicians became professionals, then they introduced the social-
organizational factors that deteriorate or enhance these traits. The authors contended
that these social-organizational factors derived from the importance of rewarding
through values created out of normative structures. Therefore, physicians were
forced to decide either to pursue recognition through organizational means, such as
research and other technological orientated measures, or through personal traits which
establish credentials with patients. This study, however, does not directly include
managed care in these organizational factors. It is apparent that such a direct
reorganization of medical care which advocates decreased patient contact by financial
means through implementing cost cutting policy is exactly what the authors intended
as organizational factors (Carmel & Gilck, 1996).
It is now becoming apparent that physicians loose certain fundamental
communication skills, as they become more adherent to advanced technological
procedures. Rudimentary interactional skills such as extracting the patients,
perspective on illness, responding to patient emotions, and deciding on a mutual
agreement on treatment are skills physicians are continually loosing due to the advent
of managed care (Epstein & Beckman, 1994). This change in physicians attitudes is
confounded by a shift of responsibility that reinvents the role of the primary care
physician (PCP). PCPs are being asked to perform additional and more complicated
procedures as capitated payment systems penalize PCPs for referrals. The American
Association of Family Practitioners is now offering training courses on procedures
such as minor surgery, orthopedic techniques, colonoscopy test, endoscopy, and
obstetrical ultrasounds (Terry, 1995). Medical economist Ken Terry further writes:
Adding to your clinical skills can save you referral cost and make
you more valuable in the eyes of HMO medical directors. However
it can increase your financial risk if capitation isnt sufficient to cover
extra services. You may also increase you malpractice risk by performing
services traditionally reserved for specialist, because you will be held to the
same standard of care as they are (1995. P.2).
Prior literature stated that a physicians behavior is guided by ethical guidelines in
which a conflict of interest does not impede the treatment of the patient. However, it
is clear that financial incentives do hinder treatment by placing physicians in a
difficult position. As depicted in the prior quote from Terry (1995), doctors are
recommended to learn new procedures they were not originally trained to do in order
to prevent sending patients to specialists. Then, Terry continues to advise primary
care physicians to take precautions because they might be held to the same standard
of care in particular areas as specialists (1995). This personification of conflict is
resounded by the willingness of physicians to shortchange their patients. Hence, the
ethos of the doctor patient relationship is corrupted by the secondary determinants
of managed care.
Purpose of Study
The purpose of this study stems from the obvious discontent shown by the
American populous toward the current health care system. With politicians debating
health care reform in order to appease this sentiment, while the HMO lobby is bracing
itself for passage, the public is left to blame the physicians. With physicians
increasingly joining capitated HMOs the issue is forced into certain questions: do
physicians value their highly specialized labor as a commodity that should be
compensated for at the patients expense? Is the very nature of capitation and medical
rationing a source of disaster for patients? Is this convoluted by the disparities in
socio-economic class of physicians and their patients? Does the shift of power and
capital within the institution of medicine from physicians to corporate managers
affect the treatment of patients? These questions represent the foundation of research
questions that engulf this study. It would not be a surprise to discover that most
physicians have an unfavorable view of managed care. This is not a sought condition
but a consensus that must be rationalized before searching for its elucidation.
Conditions sought revolve around how physicians interpret their role in populace,
although being exploratory study concrete postulates are not the purpose.
The flexibility of the interview guideline allowed the researcher to discover
physicians attitudes on managed care by how often they would refer to the patient.
The questions were deliberately designed to allow the physicians to disclose issues
concerning self-gratification and patient advocacy. The combination of these issues
allows a representation of individual dispositions that is the basis for analysis. The
guideline also served to discover the value physicians place in their services, both
monetary and social. The first question asked to the respondents was, Overall, do
you perceive HMOs as a positive or negative force in medicine? The purpose of this
initial question, in combination with others, was to determine whether the physician
internalized the effects of managed care toward his or her own life. In opposite, the
physician could externalize the concerns of managed care beyond any self-
considerations. The overall purpose of the study ruminates upon this conception of
extrinsic, intrinsic doctrine which dictates patient care and will determine the future
of managed care. This indicator is conditional on several precipitating factors, such
as the mere need to participate in conjunction with HMOs simply because a physician
does not have a choice.
The data requested from physicians served, not only to discover their personal
worldview on the efficacy of managed care, but also to determine whether medical
professionals share a sense of animosity toward those who control capital associated
with health care. The value of labor in the highly specialized field of medicine has
allowed physicians to sell their treatment as a commodity that has brought them
prestige and prosperity. With the proliferation of managed care and the shift in the
control of capital, physicians have lost the prestige and community respect they once
wielded. Therefore, other considerations that derive from the data will assist in
ascertaining whether physicians have accepted the role of being corporate
subordinates. This leads to inquiry the autonomy in patient care along with other
types of clinical freedoms physicians have enjoyed for decades, which are now
regulated by case managers and reviewers.
During the interview physicians were asked if they had ever been denied
procedures or referrals by their HMOs. They were also asked how they would
explain to a patient that such clinical determinations have been denied. These
questions are intended to ascertain how far a physician would go to uphold the
interest of their patients before coming under sanctions from the managed care
corporation. It allows for the combination of both expectations stated above in order
to re-systematize the patient advocate role. The responding physicians were asked if
the role of the patient advocate should be that of the physician or should one be
assigned from outside the medical institution. This was a very important determinant
in discovering the extent of responsibility the physician felt he or she had toward the
patient. This question was followed by another asking if the physicians ever felt a
conflict of interest between patient needs and financial incentives. Therefore, all
information resulted from these interviews compelled the respondents into the
extrinsic or intrinsic model of patient care.
The data that will be reported were collected through in-depth interviews in a
nine-day period in January 1999 in a community of 100,000 in Northern New
England. The method used to select the sample was a non-random availability
sampling technique. The respondents, physicians, were initially contacted by an
informant who was also a physician. She asked if they would be interested in
participating in a study by a Masters student in sociology studying the effects of
managed care on the doctor patient relationship through physicians perspectives.
All twenty-five physicians initially contacted by the informant agreed to consider
taking part in the study. The sample size had not been established before the initial
contact. The minimum number of physicians needed was set at fifteen, the final
number of physicians interviewed was twenty-one. Four physicians who agreed to
take part in the study could not find time to schedule an interview.
Once the physicians were contacted by the informant and agreed to consider
being interviewed, the researcher contacted each physicians office to schedule a
time. Times varied throughout the nine day period; generally the interviews would
either take place in the morning hours or in the late afternoon when the physicians
were done seeing patients for the day. Locations of the interviews varied as well.
Three physicians were interviewed in a hospital, twelve physicians were interviewed
in their offices, five physicians were interviewed in their homes and one physician
was interviewed at a public place.
One research criterion required was that the interviewees be practicing and
licensed medical doctors. The second criterion was that the physicians either
belonged to a health maintenance organization or had encountered a patient whose
health care coverage was dictated by a health maintenance organization. The third
criterion was that at least fifty percent (50%) of the sample had to be primary care
physicians or specialists who had primary care patients. The sample consisted of nine
primary care physicians (43%), specialists with primary care patients and specialists
without were as follows:
Breakdown of specialist by area of concentration
Speclialist with primary care patients 4
Pulmonary specialist 1
Ear, Nose and Throat 1
Emergency Room 1
The gender distribution of the sample population consisted of sixteen male physicians
(77%) and five female physicians (23%). The oldest physician was sixty-one years
old, while the youngest was thirty-eight years old. The average age of the sample
was approximately fifty-three years old, as depicted in figure 3.2.
Age characteristics of the sample population
N Valid 21
Std. Error of Mean 1.4885
Age is important in assessing physicians attitudes toward managed care, since
younger doctors might not have the experience working in a non-HMO environment.
Although in determining such differences, it is important to recognize that age alone
is not a component in defining experience. This is primarily due to individuals
graduating from medical school at a later age because physicians age during
graduation varies. Therefore, their year of graduation from medical school becomes
as much as a deciphering factor as age.
Year of Graduation form Medical School of sample population
N Valid 21
Std. Error of Mean 1.83
As we can see from figure 3.3, physicians in the sample population graduated from
medical school between the years of 1960 and 1989 with three physicians graduating
Marital status of the respondents was as follows; seventeen physicians (80%)
were married with children or grandchildren. Two physicians (10%) were divorced,
while two physicians were (10%) single. Seven (33%) physicians in the sample
population were bom and raised in countries other than the United States; these
countries include India, Kenya, Egypt, Greece, Philippines, and Puerto Rico. Those
physicians native to the United States are primarily from the Northeast or Midwest.
Physicians were asked to disclose where they had gone to medical school. Since this
question produced twenty-one different responses out of twenty-one respondents, it is
doubtful that any serious correlation can be made between medical school and
physicians attitudes toward managed care. Physicians were also asked to specify
their income category; only five out of the twenty-one (24%) respondents would
disclose their income category. Speculation regarding this will be addressed in the
Before each interview began, respondents were handed a consent form that the
researcher read aloud. The consent form stated that the interview would be recorded
by audiotape while the researcher took notes and that respondents had every right to
ask for the tape recorder to be turned off, which the researcher would do without
prejudice. The form also stated that their confidentiality would be protected at all
cost by implementing a numerical coding procedure that ensured the tapes, interview
notes, and identifying information could not be correlated. The respondents were also
told that they could also terminate the interview at any time without prejudice. The
form stated that the interview duration would be approximately thirty to forty-five
minutes although some of the interviews lasted almost an hour. The interviews were
not structured and some physicians were quite casual during the sessions. Yet, some
others exhibited suspicious nonverbal cues and were stringent in their answers. The
majority of the participants showed enthusiasm at the conclusion of the interview
even though some questioned the purpose of the research. One respondent in
particular requested to see the interview guideline one day ahead of the scheduled
interview. This incident will be discussed in greater detail in the next chapter. The
consent form also had the contact information of the researcher; the researchers
faculty advisor and the Office of Academic Affairs at the University of Colorado at
Denver in the event the respondent had a question on his or her rights. The interview
guideline consisted of fifty-one questions, however, not every question was asked to
every subject and not all the questions were instituted into the final analysis due to
inconsistencies and irregularities in the responses. The guideline served as
delineation to the interview that did not require consistency between all the
interviews. Physicians were allowed to answer any particular question for as long as
they wanted. They were not limited to the scope of the interview. After each
interview, the researcher thanked the respondent for their participation.
The primary researcher transcribed interviews after the interview phase was
completed. A complex pattern of coding procedures was used to discover patterns as
well as differences in the data. Matrix patterns were also incorporated as the
principal analytical device for interpretation of the data. The filed notes taken during
and after each interview were incorporated into this process in order to ascertain if
any new avenues of edification had developed.
The influences of managed care and more specifically HMOs have clearly
molded the functionality of the American health care system into an equity driven
institution. The complexity of the source of influence is at issue and ought to be
discovered through the interpretation of this data. As stated in previous chapters the
element of control in treatment is a tumultuous battle for physicians who belong to
managed care plans. Many of the respondents stated outright that their perceptions of
HMOs was negative, although these perceptions were fabricated from several
different incentives. Several of the physicians claimed that the lack of control in the
treatment of their patients and the growing of bureaucracy within these organizations
were preventing them from practicing good medical care. The respondents
condemned HMO personal as of poor quality and uneducated; thus further
illustrating that their role as the sole trusted medical provider is very much in
Respondents reported that HMOs limit choice for patients through overly
intrusive practices. According to many physicians, increased bureaucracy along with
cost conscience administrators, were the cause of these practices. Managed care,
according to many of the respondents is a sound idea, although as one physician
It has been politically, socially, and economically manipulated in a
way that it has become counter-productive. Like any business its
run like a business, all they care about is productivity and profits.
All they care about is lessening premiums and increasing profits.
The most profound conceptual phenomenon concerning physicians attitudes toward
managed care seems to be the proliferation of the profit motive within health care.
The introduction of profit and immediate monetary gratification within health care
and more specifically the introduction of capitated payment systems seems to
associated with the degradation of the traditional doctor/patient relationship. The
discourse of these perceptions would lead one to believe that physicians are not able
to control policy or contend with any condemnatory applications which might have an
adverse effect on the patient. An excerpt from a respondent illustrates:
HMOs obstruct the patient/doctor relationship by not providing a
healthy motivation, they replace quality with cost. They have also
created a milieu in which physicians are much more concerned about
the business aspect of health care. They reduce providing health care
from a profession into a job.
The majority of respondents reflected disdain for HMOs, therefore the mere inclusion
of HMOs into a physicians practice would seem rather hypocritical. If physicians
are, in fact, forced to observe financial responsibilities above those of patient needs,
then the observer would have to speculate: Why would a medical professional
sercome to such a diminished standard of care?
Under the traditional FFS plans, physicians had the capacity to dictate the
standard of care by having the power to treat patients as they saw fit. This power has
now deteriorated significantly and is almost non-existent as physicians find
themselves needing to follow managed care guidelines in order to stay in business.
This was evident as respondents revealed their frustrations with HMOs while also
acknowledging that the state, of health care is beyond their control in the words of the
I think it is a negative force, although its sort of biting the hand that feeds
you and shooting yourself in the foot because theyre the only ones around
now. The old scenario, where physicians could work with patients and had
a positive relationship has disappeared. You are either owned by them or you
There were conflicting opinions on the financial necessity of participating in HMOs.
While a majority of respondents implied they were, others strongly denounced any
participation with HMOs as a moral indignation that had placed physician
compensation above the needs of the patient. Those physicians, who reiterated their
claim of bankruptcy if they did not participate in HMOs, capitulated as to the clear
profit motive behind health maintenance organizations. Some respondents, who had
a favorable perception of HMOs, did so only in policy and theory, but also displayed
frustration and anxiety over its implementation and progression.
Any response as to the functionality of HMOs eventually led to the discussion
of capital through its control and use in health care. Several of the physicians referred
to HMOs as a marvel of medical policy, but they went on to say that the for profit
status the majority of them exhibit is detrimental to many of the foundations of health
care. With the expansion of cost containment medicine and the proliferation of the
profit motive within the treatment of the ill, many physicians have attempted to keep
their independent practice in order to avoid being alienated from any decision making
There was a clear consensus as to why physicians chose to participate in
HMOs, a vast majority of respondents said that the penetration by HMOs with in this
particular market exceeds 90% which translates into a lack of any other alternative.
There were, however, several physicians who did not accept any or one HMO and
were in practice without fear of bankruptcy as many said would happen if they did
not accept these particular managed care plans. This might suggest that there might
be ulterior motives for the participation by physicians in these HMO plans, as one
Everybody has to make a living, but to have corporations presenting themselves
as providing an umbrella of great medical care is a sham, no 1 wont participate
with people who steal. What they did was increase the number of seats in medical
school, they knew they had to control physician marketing. When you graduate
you re about $120,000 in debt, so you either going to prison or work for the man,
which is the HMO.
The majority of the respondents were able to disclose whether the HMOs they
provide their services to are for profit or whether they are publicly traded companies.
Such overt profit maximization tactics should not come as a surprise to many
physicians, especially to Primary Care Physicians (PCP).
Such tactics transcend past the corporate structure within health care and into
the physicians office. Referral practices common to HMO plans involve a referral
fund where PCPs are allocated a specific amount in order to compensate specialists
and other expensive medical procedures. If a PCP has any amount left by the date
specified in the contract with the HMO, then he or she can appropriate those funds as
part of their income. The other tactic that perpetuates the profit means of operation
within health care is capitative payment systems. This compensation system for
physician is based on payment per member per month as specified in the physicians
contract. It is important to reiterate these tactics because they provide the basis for
the conflict of interest that is inherent to the profit motive within health care.
In order to discover whether physicians appropriate the profit motive within
their professional conduct, the respondents were asked if they believed patients were
treated differently before the advent of managed care. The physicians reported that
the intrusive nature of HMO business practices aversely affect the doctor/patient
relationship. There are precipitating factors that fuel the adversarial character that has
become inherent within this relationship. However, the blame does not solely rest on
the business practices of HMO companies. The shift of power from health care
policy to HMOs was allowed without significant protest from the American Medical
Association. Therefore, as the respondents repeatedly voiced their disdain for HMO
treatment-reviewing procedures, which emphasize cost containment, it was apparent
that the majority of them were not inclined to suggest that the current health care
system was fundamentally flawed. This sentiment was prevalent in light of the
respondents obvious knowledge of the state of health care in the United States, as the
following quote demonstrates:
I know they were treated differently. The difference is between one week
and two months for breast cancer growing in a womans chest. If she has
an HMO she would have never had the cancer removed. She would have
never had a bone marrow transplant, you see it all the time. There is a big
difference in the quality of care.
Such inadequacies in health care are detrimental to the doctor/patient relationship,
because it aligns the physician against the patient. Delays in treatment are due to the
amount of restrictions placed on physicians by HMOs in order to cut cost and secure
profits. These restrictions further mitigate any compassion and altruism that have
traditionally been the disposition of the physician. This shift in predilection has
alienated the physicians, as well as the patients from traditional social systems that
allowed the medical professional to be integrated into the community.
As the profit motive solidifies the determining factor with in health care it
continues to place the patient at a disadvantage. Physicians scrutinize their treatment
plans in order salvage their reimbursements:
There is low reimbursement and a number of patients to see in a day,
there is less time we can afford to see patients since managed care
patients are more demanding, but there are restrictions in your practice
as to how many patients you can see and how quickly. A primary care
physician cannot spend more energy and time than he can make with
reimbursement. He cannot have a patient come to his office that cost him
money, he would be out of business.
Certain restrictions limit the amount of time a physician is allowed to interact with a
patient during an office visit. Even though this quote suggests that certain physicians
only commit as much time as they are compensated, it prompts one to ask, are
managed care patients more demanding of frivolous medical care than FFS patients?
The answer is an unquestionable no. Patients who are forced to participate in HMO
plans are acclimatize to a high standard of care that was the norm during FFS. Upon
the integration and implementation of HMOs, the standard of care diminished rapidly,
leaving patients bewildered.
With the growing dissatisfaction toward HMOs, patients are loosing faith with
the medical community and the institution as a whole. During the course of the
interview, the respondents were asked if they felt physicians had lost a sense of
respect from patients with the proliferation of HMOs. A vast majority of respondents
felt as they had. Physicians, according to many of them, said they are too easily
identified with the insurance company. The transition from a dichotomous
relationship between the patient and the physician into a impersonal business
agreement that is dictated by the insurance company has reinvented the physicians
The physicians role has transformed from that of an advocate healer to a
corporate agent who denies the necessary care to patients. According to some
respondents, social systems that have allowed physicians to be trusted community
leaders have virtually disappeared. Lines of communication, which at point can
transcend life and death medical decisions by physicians, are now subject to filtration
as HMO case managers rewrite the physicians treatment plan in order to be cost
effective. All of the respondents demonstrated clear dissolution in terms of the
dismantling of the doctor/patient relationship and acknowledged that this was clearly
due to integration of the profit motive. However, many respondents also stated that
patients should be able to demarcate as to what extent a physician could control over
their treatment ends. This sentiment was declared in a rather unabashed tone,
implicating a clear frustration over the loss of power within the medical
With increasing media attention on the proliferation of the profit motive
within health care, patients, according to some respondents, are associating this with
physician compensation. It would be difficult for patients not to reach this
conclusion, since more and more physicians are employed by HMOs. Therefore, it
would be difficult for the medical professional to remain as an unbiased entity during
treatment and cost disputes between the patient and the HMO. Compensation
systems for physicians employed by HMOs are based on withholding care as one
Youre not paid fee for service. The money is not given to you for doing, the money
is given to you for not doing; there is a difference. The more you withhold care,
the less service you provide and the less time you spend with a patient, and the
less medicine you give the patient, the more money you make. 1 think there is
often a delay in diagnosis and I think theres inadequate treatment. I think patients
are more reluctant to go to physicians because of the motion that HMOs are out there
and physicians are adversaries. I think people die unnecessarily because care is not
delivered in a timely manner and the goal of care for the patient is to save money and
Withholding care as a normative practice in order to aggrandize financial gain within
health care, bolsters the perpetuating nature of profit maximization and the
contradictory effect corporate enterprise has had on the institution. It is a clear result
of an accouchement by one principal social system based in economics and more
specifically capitalism, on a subsystem that had traditionally been based on human
need and ignored by those who control capital. The consequence is now apparent as
physicians struggle with conflict of interests and become more alienated from their
former position of power and community status.
Managed care has been associated with rationing medicine and the equivocal
interpretation of what amount of medical care is sufficient in order to treat patients
effectively. The respondents were asked if they felt health care must be rationed due
to increasing expenditures. If these physicians sensed that the current health care
system was in an upward financial spiral due to increasing technology and profit
maximization by corporate interest then they could advocate for rationing and
demonstrate an unwillingness to be coerced by the profit motive. The majority of the
respondents (92%) stated that they did not feel heath care should be rationed.
However, with the withholding practices instituted by HMO companies and the
financial incentives presented to physicians, a paradox within the system is created by
not suggesting health care should be rationed. During Fee-For-Service, according to
some respondents physicians were criticized for practicing frivolous medicine and
ordering unnecessary procedures. Currently, under managed care physicians are now
criticized for not ordering enough tests and other expensive procedures. These polar
practices coincide with what is and was the best instrument for financial gain at the
In terms of how much autonomy physicians have in treating their HMO
patients, they might not have much area to maneuver. Nonetheless, physicians
voicing their opinions on the negative aspect of rationing while practicing managed
care, are advocating selective health care that reaffirms an equity principal that is so
entrenched in an open market economy. One respondent suggested that he might
have influence on how he interacts with his patients, however, he does not have any
significant prestige in the formation of medical policy.
I feel that 1 have a lot of control over what my relationship is with my patient.
As far as prescribing medication, I am controlled by the bottom line. I always
answer ultimately to the HMO because they can decide to shut me out tomorrow
if I am not economically credentialed, and that means if I loose money from the
company then they can withdraw their support and withdraw my participation.
They can drum up some kind of national quality assurance committee criteria,
and just decide I dont fit that criteria, and goodbye doctor, then doctor says
goodbye to patients let me go and dig ditches.
With such a seemingly repressive and restrictive system, it would be irrational to
conclude that physicians would advocate this type of medical care if they did not have
other vital interests for supporting it. If physicians are, in fact, just pawns of a
restructuring health care system, than to allow this type of degradation of care would
be inconstant to any oath and vow they have sworn to uphold.
Health care expenditures have been rising steadily over the last several
decades. According to a majority of the respondents, technology has been
responsible for the increasing cost, as physicians ordered more complex tests and
procedures during Fee-For-Service. Procedures such as MRIs and CAT Scans have
been excessively used throughout medicine especially during end of life care. A
majority of the physicians interviewed overtly stated that the over use of technology
by physicians in the past led, to the need for some form of managed care.
Several reasons could account for physicians ordering these tests needlessly during
end of life care. Primarily, the deficiency in compassion and emotional healing that
had once been so vital in the doctor/patient relationship. Prior to the advent of
technological medicine, physicians relied on their interactional skills to ease the
suffering of terminally ill patients. In contemporary medicine, physicians are at a loss
on how to manage terminal issues and lack the social proficiency to treat these
patients adequately as a respondent states:
I think there is a lot of futile treatment done, by the fact that there is
not good communication. There are people who are terminally ill,
and who should be encouraged to make advanced directives and decide
not to have resuscitative measures. Many times, things are advised to
people that are not in their best interest. It is the most important thing
to decide with the patient about their quality of life, what they expect,
which is very difficult at times to make a decision. They are going to
prolong death, not prolong life. Many time money is spent in prolonging
death, which is a result of poor communication. Millions of dollars are
spent in prolonging death.
Technology replaced communication as the principal avenue of standard medical
treatment and led to the creation of managed care, thus allowing the further
degeneration of the doctor/patient relationship.
Patient attitudes toward HMOs greatly influence physician status in the
community. Medical professionals are aware of this, and according to the
respondents, are mindful of the growing discontent toward inadequate medical care.
When asked if their patients are content with the HMO, the vast majority of
respondents stated that all or mostly all of their patients were completely dissatisfied
with their HMOs. The two principal complaints the interviewed physicians cited
were patients wanting to be seen much earlier than they have been. In the worst
instances, patients needed to wait several weeks before an appointment with their
primary care physician. These delays in scheduling coincide with several respondents
admitting that HMO patients were not scheduled as quickly as those with amenity
insurance. Since physicians are compensated far less for HMO patients than those
with Fee-For-Service, through the profit maximization tenets it would be logical for
them to see the more affluent patients first.
Secondly, patients object to not being seen by the physicians themselves.
Nurse practitioners and physician assistants often see patients while physicians are
compensated for visits they never took part. Stipulations within the compensation
system most prevalent within HMOs force physicians to see twice as many patients as
they did before the advent of managed care in order to maintain similar remuneration
as they did during amenity insurance. In addition, physicians are also aware of
patient discontent toward shoddy referral practices that plague primary care
physicians. Some respondents clearly stated that they delay any referral to specialist
as long as possible, leaving specialists to see patients with illnesses in an advanced
and almost incurable condition. This further establishes the motivation behind
managed care payment systems, which forces a conflict of interest in the
patient/doctor relationship. When compelled to make such decisions not all
physicians are prone to follow the traditional norms of the doctor/patient relationship:
Ill just come out and tell my patients that they have policy X and
when they have policy X, I dont work for them, I work for the
HMO. 1 tell them I am not their personal physician because they
have chosen that particular plan.
The rationalization behind not having the patients best interests in mind further
illustrates the physicians loss of power. This particular respondent sees himself as an
employee of the HMO, therefore it allows him to justify cost cutting procedures by
telling the patient that he is not responsible.
In the HMO hierarchy, a physician needs to obtain pre-authorization for any
procedure that the HMO deems to be not cost effective. HMO personnel approving
these procedures are registered nurses who are paid to be cost conscience and
scrutinize treatment plans that involve these expensive procedures. The responding
physicians were asked if they felt these case managers were more concerned with
saving money rather than having the best interest of the patient in mind. The vast
majority of the respondents enthusiastically stated that these case managers did not
have interest in the patients health or well being:
I can tell you as a father of a kid who is on chemotherapy, who ultimately
got into it with a manager because of the expenses of the care, it was
absolutely true clear that the health of my child was not at all in their
thoughts. The manager only comes in when the insurance company sees
that there is some money hemorrhaging from somewhere, and their function
is to plug up that hemorrhage.
Such sentiments are common among patients, even though these types of practices
should not be a surprise as HMOs do not attempt to hide that their main concern is
cost containment and to provide a healthier bottom line rather than a healthier patient.
Therefore, problems within heath care cannot rest with an institution that is following
the normative structures that are so prevalent among all social organizations in
American society. If an equity driven system is allowed to flourish in other sectors of
society then the indoctrination of the profit motive within health care is a natural
progression toward the perpetual steadfastness of the society.
However, the conflict within health care rests solely on the shoulders of
physicians. Doctors have taken an oath to treat their patients to the best of their
abilities, yet the very nature of managed care contradicts this and impedes their ability
to do so. Many respondents complained that the amount of work is so overwhelming
that they do not have time to ensure all the patients needs are being met. With
financial and administrative pressures placed upon them by HMOs, physicians do not
have the ability to advocate for the patient in instances of dispute. This is especially
true if the HMO employs the physician, where the risk of termination is high.
Respondents were asked if they believed patients should be assigned a patient
advocate from outside the system or if that should be the role of the physician. A vast
majority of respondents expressed that the role of the physician should include being
an advocate for the patient. Even though the consensus was that physicians are
generally to busy to become involved in all aspects of the patient rights, they declared
that no other person other than a medical doctor could fill such a role.
Physicians generally felt that although a patient advocate might be beneficial
to the patient, it would represent further intrusion into the realm of which they
operate. This encroachment would further represent the dismantling of the
doctor/patient relationship and the continual degradation of physician prestige. With
the increasing conflict of interest experienced by physicians and the loss of
autonomy, certain respondents felt that it was too late for physicians to fill that role.
There was concurrence among respondents that a patient advocate must have
complete autonomy if they are to fight for patient rights. However this produces a
paradox. For physicians to be adequate advocates, they must be absorbed in the
system. Physicians involved in the HMO machination either are employed by the
HMO or do not have complete autonomy, therefore they would be poor patient
Respondents were asked if they would risk being dismissed from an HMO
membership to ensure that the interest of one patient is held above everything else.
Reactions were mixed to this particular question. The precise words used when
asking the question were if they would risk being fired from an HMO membership.
The responding physicians had difficulty seeing themselves being in a situation where
they were subject to dismissal for poor performance. Many responded by insisting
they would resign if any of the patients rights were violated, although the ofiten-
shrewd tone they presented was obvious. The interpretation behind the impertinent
manner suggested that physicians were apprehensive about displaying any indication
that they are losing any further status in the community.
The majority of the respondents ultimately agreed they would in fact be
willing to be dismissed rather than betray the doctor/patient relationship. However,
physicians do not have the luxury to dictate the terms of treatment. If a physician
were to be dismissed, the patient would not retain the services of that particular
physician but would simply have to choose a more compliant physician within the
particular network. Which such inability to control the direction of medical care and
the degeneration of their social status, respondents were asked if they felt any
resentment toward HMOs. Resentment was wide spread over numerous issues
ranging from diminishing autonomy and increased administrative responsibilities,
although the incorporation of the profit motive into the doctor/patient relationship
was the prevailing sentiment:
Theyre in it for the money, theyre not altruistic, I dont think health
care should be traded in the stock market. Overall, although there are
many willing prostitutes among us, somebody has to be a pimp, according
to the line of the businessman and so were being pimped. The pimp is
running the show, and the prostitutes dont have much to say, and thats
what we have become.
Respondents also displayed disillusionment in regards to their lack of capacity to
modify the mechanism of medical policy. Many expressed a sense of embarrassment
that the failure of health care is dictated in terms of lost profits rather than deaths of
When asked if physicians should have the final say in shaping the health care
policy for the next century, many respondents surprisingly stated that there needed to
be a combination of professionals such as civil leaders, lawyers, and others
determining regulations. Even though the consensus was that no other professional
has the interest of the sick and injured at heart, the respondents admitted that there
needed to be regulatory instruments inserted in order to ensure that medical care is
distributed equally and fairly. However, as the following respondent states, the profit
motive has infiltrated and Coerced any progress toward this goal, while diminishing
any sense of hope and trust we have toward our healers:
Physicians have very little to say because physicians have been divided
and conquered. The managed care administrators are not physicians.
Theyre the ones calling the shots. We also have traitors like physicians
who have chosen to be administrators and have become big wheels like
the director of an HMO who makes $20 million a year. Nobody is worth
$20 million dollars a year, absolutely nobody. Jesus Christ came much more
cheaper and did much more work for humanity than this guy. I think that it
is a immorality, the way health care is now. To me its blood money, profit
from somebody being sick, denying care, denying medicine and referrals.
Physicians need to get back to their jobs of being patient advocates
before its to late.
Differences in convictions did not reflect gender differences in the sample
however, there were tremendous differences in terms of the age of the physician.
Older respondents, those who had been practicing medicine for over three decades
were more likely to overtly disagree with the HMO and were less fearful to fight
HMO decisions than their younger counterparts. Older physicians were also more
likely to risk being terminated for their beliefs since they did not have to worry as
much about the development of their careers. Younger doctors who are trying to
establish a practice must be financially credentialed before being hired as regular staff
by an HMO. With the continual disappearance of independent physicians and the
amount of new physicians arriving out of medical school, the chances that all new
doctors will find immediate employment is slim.
CONCLUSION AND LIMITATIONS
The prevailing social system within the sphere of American society consists of
equity driven values that perpetuate normative structures through all social
institutions. As mentioned numerous times in the preceding chapter, the institution of
health care has been indoctrinated into exhibiting unscrupulous moral indignation.
However, the profit motive applied to other social systems is celebrated within
American culture as a triumph of free enterprise. Physicians have found themselves
in a precarious position, bound by an oath to have the interest of their patients in mind
though threatened to comply with financial and administrative constraints. The results
have been a disastrous aggregation of interest that provides poor and dangerous
medical care for the American populous.
The denunciation of the HMO system cannot clearly be the answer for
physicians seeking to reacquire loss reverence among patients. The loss suffered by
medical professionals entails much more than social status and power to dictate
medical policy. The doctor/patient relationship has been coerced by the same
fundamental virtues that we as a society have grown to depend for our economic
survival. The expectation the public bestows on medical professionals lingers on the
mythical, as if they were beyond any corruptible state. Normal societal attributes
such as acceptance of the profit motive, which are determined by the status quo, have
placed an undo burden on physicians. The results suggested that physicians are
struggling with maintaining the integrity of the doctor/patient relationship, because
they have been compelled to anticipate the consequences of negative financial
This impediment has solidified among the only social institution patients have
come to expect to exhibit altruistic practices, therefore invoking a fierce reaction
toward physicians. The inability of physicians to advocate for patients rights is the
result of the financial constraints placed upon them by HMOs, thus vilifing their
intentions. The medical community is, as one respondent described at war with
interest that seeks to diminish the capacity for them to be healers. Public opinion
toward physicians has plummeted as patients bare the brunt of cost contained
medicine. At the same time, HMOs have record profits. Many respondents were
adamant about blaming managed care for their plight, but others were less apt to point
their fingers. After all, they indicated ultimately it was the physicians who allowed
HMOs to grow to the force they are today. As private enterprise initiated the
managed care boom by allowing HMO parent companies to sell publicly, medical
professionals knew very well that a positive bottom line would be a primary concern.
Prestige is an extensive component of the doctor/patient relationship, over the
last decade physicians have seen their profession fall from the most trusted and
respected in society to that of a corporate goon. The obvious loss of physician power,
which has coincided with the advent of managed care is an integral portion of this
analysis, because it provides alternative hypotheses for their lack of action.
Therefore, the introduction of the profit motive cannot serve as the sole incentive for
physician contempt toward HMOs. This analysis raises many questions concerning a
physicians motives about the sub-standard care that is so common with HMOs. Why
would a medical doctor allow him or herself to deliver such dilapidated care if other
incentives were not involved? Many respondents presented themselves as not having
any alternative, and this was their principal reason why they tolerated HMOs. This
rational provides several interesting possibilities; either physicians capacity has been
degraded beyond their ability to incur the most simplistic request or there is the
possibility that respondents were not being truthful.
The responding physicians were surprised at the line of questioning being
asked during the interview. It was apparent that any question concerning their
augmentation to the degradation of health care was perceived as impertinent. Certain
respondents challenged the very need for these questions and insisted that the media
and other channels of information created the perceived physician connection to the
deterioration of medical care. However, some respondents were sincerely
embarrassed when disclosing behaviors of other physicians who had fought a conflict
of interest and lost. There was an obvious attempt for the interviewees to vindicate
their profession by asserting that in perilous situations, they where in fact doctors
with the health of the patient above everything else. Nonetheless, this assertion of
moral aptitude was consistent with their privation toward loss of status in the
At times, respondents displayed an impression of hysteria as they interrogated
the researcher for fear of reattribution by their HMO employers. Respondents asked
if the researcher had any connection with HMO management and if they had
commissioned the nature of the study. One respondent went as far as demanding to
inspect the questionnaire before the researcher was allowed to proceed with the
interview. When asked as to why he would need to take such precautions, the
physician stated he did not want to divulge any sensitive information about his
practice. At first, such prudence would seem rather absurd to those not familiar with
tactics used by HMOs to force physicians to comply. However, as one respondent
stated the need for safeguards is warranted:
You are told by the HMO to be cost effective. You have to provide cost
effective medicine. They come with statistics and compare to other
physicians. Indirectly they intimidate you. You have to go along with
the other physicians. Then you worry about whether or not you can
continue your practice.
This type of predilection emphasizes the financial ultimatum physicians are forced to
face. The expectations for physicians are congruent with those normative structures
within the corporate culture. However, as mentioned in pervious chapters, older
physicians are more likely to voice their discontent to this system by overtly
disobeying HMO restrictions and organizing physician collective bargaining groups.
A fundamental rift has arisen between PCPs and specialist over the
impediments placed by HMO restrictions. Specialists in the study are not
compensated by capitation, but with the traditional payment system of Fee-For-
Service. Specialists have seen their patient load diminish as PCPs are more hesitant
to refer patients to them until the problem becomes grave. The level of resentment
toward specialists by PCPs has been rising steadily, because specialists have
benefited by accepting patients who have advanced forms of disease. This translates
into more procedures that are expensive and medication at higher price, specialty
doctors can ask the individual patient and the HMO. This sentiment seems to be
apparent in certain specialties, because not all specialists interviewed shared this type
of optimism in regard to HMOs. Specialties such as surgery seems to be have the
same complication suffered by PCPs, while specialties such as neurology have not
been affected negatively and have even seen their practices improve during the
transition to managed care.
The profit motive invoked in health care has also produced a sort of
bewilderment among physicians. Those respondents who were either raised or
trained outside the United States had a distinct vision on this intrusion. These
physicians rationalized by insisting the current dilemma in health care was not
centered around medicine alone, but rather saw it as a reflection of American culture.
Gender distribution did not reflect any significant variance in attitudes toward
managed care, although age differences displayed a substantial difference. Certain
physicians who were interviewed were surprisingly not up to date on the functionality
of HMOs. One respondent, in particular, a PCP, who has been practicing medicine
for twenty years, could not comprehend questions surrounding rationing, autonomy
and status in their relation to managed care. This particular physician was also in
strong support of HMOs with the rational that they allowed for wide spread coverage.
This perhaps could be feasible, although with the overwhelming majority of
respondents contradicting this view, one must consider the reliability of this
physicians knowledge on managed care issues. This however, was not the norm. The
majority of respondents were well versed in HMO practices and were insightful in
their interpretation of the negative and positive aspects of managed care.
The data gathered was qualitative in nature in order to fully gather the
physicians accurate sentiment toward managed care. It is the researchers
consideration that attitudes on loss of status could only have been understood through
the physicians interpretation of HMOs. This study sought out to explore the reasons
and effects of the physicians loss of power within the medical community and how
this reverberated in the doctor/patient relationship. It did not seek to demonstrate or
debunk and hypotheses within the theoretical basis of social organization. Through
its results, however; new hypotheses can be constructed and perhaps investigated
through quantitative methodology. However, clear indictors must be present, a
component which was not clear in this study due to the deficiency of structure in the
The sample was limited to one geographical area, which severely limited the
conditions relevant to HMOs. HMOs operate independently and do not have any
cognate uniform procedures. HMOs throughout the United States will demonstrate
different tactics in managing physicians and treatment of patients. In order to fully
address the scope conditions necessary for a fully ranged study on this subject would
require resources unavailable to the researcher. The sample consisted of twenty-one
respondents, which allowed legitimate physician attitudes to be recorded. However,
any follow up would require a lager sample or the transformation between a cross
sectional to a longitudinal research design. The alteration in research design would
allow physicians perceptions to be recorded overtime which would also allow the
researcher to study the continual degradation of the physicians power and status.
Results from this study are destined to be extensive in any future
consideration in the analysis of managed care. As this study suggests, physicians
efforts in the formulation of health care policy have been futile. This would imply
that the development of policy is solely in the hands of HMO parent companies,
which have a personal stake in perpetuating the profit motive beyond any justifiable
doctrine. It is within this discourse that prospective policy implications may
investigate other arenas for information regarding managed care. It is the
researchers sincere hope that this other arena is beyond the scope of financial
influence by those who control capital in the institution of health care.
A. MANAGED CARE PHYSICIAN INTERVIEW GUIDELINE
2. Parents level of education?
3. Were did you grow up?
4. Where did you go to medical school?
5. What year did you graduate from medical school?
6. What is your marital status?
7. Do you have children, grand children?
8. Please specify what category your income fall? 31,000; 60,000 61,000; 90,000 -
91,000; 120,000- 121,000; 150,000 151,000; 180,000 181,000;210,000 -
211,000; 240,000 241,000; 270,000 271,000; 300,000- 300,000+
1. Overall, do you perceive HMOs as a positive or negative force in medicine?
2. Are you and your family enrolled in an HMO? If you are do feel this plan meets
you and your families needs?
3. How many managed care plans do you provide your service too?
4. Would you recommend the managed care plan you provide your service to, to
your close friends?
5. Are you aware if they are for-profit or non-for-profit?
6. Why do you participate in HMO plans (reasons)?
7. Do you know what insurance plan your patients have when they come into you
8. In you opinion, where patients treated any differently before the advent of
managed care (HMOs) by primary care physicians?
9. Do you think all patients are treated equally regardless of health insurance by
primary care physicians?
10. Are you paid by capitation?
11. Are capitated patients treated differently that Fee For Service patients?
12. Do you feel health care must be rationed due to increasing expenditures?
13. Do you feel physicians have lost a sense of respect from patients, with the
proliferation of HMOs?
14. How much autonomy do you have in your treatment of patients in HMO plans?
15. Do you adhere to recommended HMO guidelines for treatment of each patient?
16. Do you order test you feel are required for diagnosis regardless of the health care
17. Have you ever been questioned about a test you ordered the health plan deemed
18. Do you prescribe the proffered medicines of the health plan? Even when there
might be drugs with better efficacy for a particular condition?
19. Do you become annoyed when a patient brings up a concern other that the
scheduled of visit was for?
20. Do you, or would you address these concerns? If not what do you say to the
21. Has a patient ever confronted you about not given enough time to fully address
22. Has a patient ever confronted you about not being able to establish a personable
relationship with you?
23. Could you say your patients are content with their HMO?
24. What % would you assume are satisfied?
25. Is the type of health plan/insurance the patient has, make a difference in your
decision to refer them to the emergency room?
26. Is your decision to refer a patient to a specialist affected by the patients health
plan? How so?
27. Does your decision to discharge a patient from the hospital affected by the
patients health plan? Have you ever felt forced to discharge a patient
28. Do you ever feel health plan case managers are more concerned with saving
money for a healthier bottom line rather than a healthier patient?
29. What criteria do you need before you give an HMO patient a referral?
30. When you are denied a referral to a patient by an HMO, what explanation do you
give the patient?
31. Is your income based solely on capitation or is it a combination of payment
32. How large would you categorize your financial risk when referring (capitated)
33. Do you rely on any sort of excess referral fund for part of your income?
34. If the HMO has a referral fund, does this affect your decision in giving a referral
to the patient?
35. How has the proliferation of HMOs affected you income?
36. How do you think capitation has affected the quality of care?
37. Do you feel that capitated payment systems are necessary?
38. Do you think patients benefit from capitation? How or why not?
39. Do you feel you are fairly compensated under capitation?
40. What criteria do you use in determining whether you are fairly compensated?
41. Do patient opinions concerning physician compensation matter to you?
42. If the hospital you are affiliated with receives capitated compensation, does that
make a difference in your decision to discharge the patient?
43. Do you feel its proper for hospital to be remunerated by capitation?
44. Are (capitated) HMO patients scheduled for appointments as promptly as those
who are not?
45. Do you spend as much time with capitated patients as non-capitated patients?
46. Do you think a patient should be assigned a health care advocate by the system?
47. Do you think the primary physician should be the patients advocate?
48. Do you ever feel you have a conflict of interest between patient needs and
49. Do you think it is ethical for stockholders to make money of health insurance?
50. Hypothetically, would you risk being fired from an HMO membership to ensure
the interest of the patient is above everything else?
51. Do you support bipartisan congressional patient bill of rights legislation?
52. Do hold any resentment against your HMO or case manager?
53. How important is it for you, that physicians have the final say in the shaping of
health care policy for the next century?
Respondents ethnic group:
Was the respondent: Very Not at all
Cooperative: 1 2 3 4 5
Suspicious: 1 . 2 3 4 5
Hostile: 1 2 3 4 5
Communicative: 1 2 3 4 5
Distressed: 1 2 3 4 5
Angry: 1 2 3 4 5
Sad: 1 2 3 4 5
Uninterested: 1 2 3 4 5
Avoiding: 1 2 3 4 5
Snobbish: 1 2 3 4 5
1. During the interview, were there any interruptions? Explain:
2. Were there any significant problems with the interview?
3. My assessment of the respondents truthfulness (authenticity) was:
4. How much difficulty did the respondent have in understanding the questions?
5. Was the respondent acting derogatory toward the interviewer?
6. How was I as the interviewer?
I am respectfully asking you to take part in a study on the effects of health
maintenance organizations (HMO) and capitated payment systems have on the
physician/patient relationship through the physicians perspective. This research is in
partial fulfillment of my Masters of Arts degree in sociology through the University
of Colorado at Denver. Your will be asked a series of open-ended questions in which
you may answer in anyway you like. The duration of this process should be
approximately forty-five minutes one hour.
The questions will seek to discover your relationship, personal views, and problems
with HMOs you either work for, have encountered or have a patient who has been
referred from. The results from this study should help to discover the effects of
managed care has had in your treatment of patients and allow for larger policy
implications for the development of managed care. By participating in this interview
you are contributing to science by furthering the body of knowledge in the filed of
Participation in this study is completely voluntary and you are free to withdraw your
participation at any time without prejudice. This interview will be recorded by analog
tape, at any time throughout the interview, you can tell me to turn off the tape and I
will do so without prejudice.
With participating in this study there exist the potentiality for certain risk to you, first
there is minimal economic risk under certain assumptions. If you disclose potentially
damaging information about a health maintenance organization and your identifying
information and that of health maintenance organization is revealed, then you may
suffer some repercussions. There is also a legal risk that you may be subjected to
litigation from the health maintenance organization and other legal sanctions from the
medical community that might include fines.
Confidentiality will be protected at all possible cost, all identifying information will
be omitted when transcribed. Analog tapes will be stored at the Department of
Sociology at the University of Colorado at Denver. A numerical coding system will
be implemented, known only to me in order to any correlation between the analog
tapes and any identifying information. There does exist the possibility of reprisal
from health maintenance organizations if damaging information is disclosed. Yet,
this is under the enormous assumption that health care organizations have gag rule
that disallow you from disclosing any mistreatment of patients. There is however
risks in divulgence of identifying information to you if your patients were to
appropriate this information. This risk is compounded if you state that financial
incentives cause you to have a conflict of interest.
If you have any questions before, during or after the study has been completed you
can reach me or my faculty advisor, Dr. Candan Duran-Aydintug at the Department
of Sociology, University of Colorado at Denver P.O. Box 173364 Denver, Colorado
80217 (303) 556-3510. Questions concerning your rights as a subject may be
directed to the Office of Academic Affairs, CU Denver Building suite 700, (303) 556-
Your participation in this study is greatly appreciated!
Herminio G. Miranda
I understand the above information and give my voluntary consent to participate in
I also understand I have the right to keep a copy of this form for my records.
Signature and Date
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