Extraordinary growth in managed care arrangements over the past decade has been both widely praised and criticized. Proponents and critics agree that the nature of medical practice is being profoundly altered by this growth, even if they cannot articulate the direction and consequences of this change. We explore the roots of this uncertainty by examining the available evidence on critical features of the arrangements managed care plans currently have with affiliated physicians. Our approach is to review and synthesize the literature in several key substantive areas from a broad range of sources. We found that existing knowledge is dated, derived from a limited subset of plans, inattentive to important structural diferences between plans, and responsive to a very naorow set of issues poorly rflecting the range of medical practice and change introduced by managed care We highlight key questions of interest and the knowledge gaps critical to address so that policy and management decisions can both reflect and be informed on these issues that define the arrangements managed care plans make with physicians and ultimately influence medical practice.
Get full access to this article
View all access options for this article.
References
1.
Aetna goes doc hunting to staff its new primary care offices . 1993. Managed Care WeekNovember 1, p. 3.
2.
Anders, G.1993. More managed care systems use incentive pay to reward "best" doctors. Wall Street JournalJanuary 25, p. B4.
3.
Ballard, M. , and M. Terze. 1993. Automated credentialing: A practical approach to quality measurement. AAPPO Journal36:10-13.
4.
Berenson, R.1987. Hidden compromises in paying physicians: Business and HealthJuly:18-22.
5.
Berenson, R.1991. Aphysician's view of managed care. Health Affairs10(4): 106-119.
6.
Berkowitz, E. , and W. Wolff. 1988. Group Health Association: A portrait of a health maintenance organization. Philadelphia, PA: Temple University Press.
7.
Berwick, D. , and K. Coltin. 1986. Feedback reduces test use in a health maintenance organization. Journal of the American Medical Association255:1450-1454.
8.
Betty, W. , H. Hendricks, H. Rucchlin, and R. Braham. 1990. Physician practice profiling: A valuable information system for HMOs. Medical Group Management JournalNovember/December:68-75.
9.
Biskupic, J.1993. Justices uphold ruling on hospital-insurer contracts. Washington PostNovember 30, p. A16.
10.
Braham, R. L. , and H. S. Ruchlin. 1987. Physician practice profiles: A case study of the use of audit and feedback in an ambulatory care group practice. Health Care Management Review12:11-16.
11.
Brasher, P. , and C. Sweeris. 1991. Resolving the National Practitioner Data Bank dilemma. AAPPO JournalSeptember:27-33.
12.
Bronow, R.1993. HMO physician shared risk pools are dangerous to patients' health. HealthSpan10(1): 9-12.
13.
Burda, D.1991. The two quality faces of HCHP. Modern Health Care21(11): 28-31.
14.
Burns, L. , and D. P. Thorpe. 1993. Trends and models in physician-hospital organization. Health Care Management Review18(4): 7-20.
15.
Burns, L. , M. Denton, S. Goldfein, L. Warrick, B. Morenz, and B. Sales. 1992. The use of continuous quality improvement methods in the development and dissemination of medical practice guidelines. Quality Review Bulletin December.434-439.
16.
California Blue Shield adopts RBRVS-based fees for PPO docs . 1994. Managed Care WeekJanuary 17, p. 3.
17.
Cave, D.1993. Incentives and cost-containent in prmarycare physician reimbursement. Benefits Quarterly9(3): 70-77.
18.
Cave, D. , and L. Tucker. 1990. Can physician capitation survive in the 1990s-HMOs will need to offset systematic risk. Paper presented at the Group Health Association of America conference, Los Angeles, California, June.
19.
Church, D.1989. An alternative to primary care capitation in an IPA-model HMO. Medical Interface2(11): 37-39, 41-42
20.
Cooper, P. , and K. Green. 1991. The impact of state laws on managed care. Health Affairswinter:161-169.
21.
Day, K.1993. A rush to "buy" doctors. Washington PostNovember 5, p. A1.
22.
de Lissovoy, G. , T. Rice, J. Gabel, and H. Gelzer. 1987. Preferred provider organizations one year later. Inquiry24(Summer): 127-135.
23.
DeLoitte and Touche . 1992. U.S. hospitals and the future of health care. Boston, MA: DeLoitte and Touche.
24.
Diller, W.1992. Physician fee schedules help employers control cost increases. Business and Health10(8): 22-26.
25.
Ellenberger, A.1993. Managed care and physician contracting skills: Questions to ask. American College of Surgeons Bulletin7(5): 30-33.
26.
Felt, S. , H. Frazer, and M. Gold. 1994. HMO primary care staffing patterns and processes: A cross-site analysis of 23 HMOs. Washington, DC: Mathematica Policy Research.
27.
Findlay, S.1993. Profiling systems aim to eliminate second guessing of doctors. Business and HealthApril:58-64.
28.
Fisher, N. , S. Howard, and D. Pasternak. 1993. Critical factors in recruiting health maintenance organization physicians. Health Care Management Review18(1): 51-61.
29.
Franks, P. , C. Clancy, and P. Nutting. 1992. Gate keeping revisited-Protecting patients from over treatment. New England Journal of Medicine327(6): 424-429.
30.
Freudenheim, M.1993. Physicians are selling practices to companies as changes loom. New York TimesSeptember 1, p. A1.
31.
Friedson, E.1975. Doctoring together: A study of professional control. New York: Elsevier Scientific.
32.
Group Health Association of America . 1988. Unique approaches to case management. GHAA News29(2): 7-11.
33.
Group Health Association of America1992. Industry profile. Washington, DC: Group Health Association of America.
34.
Group Health Association of America1993a. The recruitment experience of health maintenance organizations for primary care physicians. Washington, DC: Group Health Association of America.
35.
Group Health Association of America1993b. Industry profile. Washington, DC: Group Health Association of America.
36.
Group Health Association of America1993c. Open-panel provisions applicable to HMOs: Laws and 1993 proposals. Washington, DC: Group Health Association of America.
37.
Gold, M.1991. HMOs and managed care. Health Affairs10(4): 189-206.
38.
Goldfield, N. , H. Berman, A. Collins, R. Cooper, D. Fragalin, P. Kongstvedt, N. Payson, P. Siegel, A. Southam, and E. Weis. 1992. Methods of compensating physicians contracting with managed care organizations. Journal of Ambulatory Care Management15(4): 81-92.
39.
Gottlieb, L. , C. Margolis, and S. Schoenbaum. 1990. Clinical practice guidelines within an HMO: Development and implementation of quality improvement model. Quality Review Bulletin16:80-86.
40.
Gnessin, A. 1990. Discrete capitation elements and provider stop-loss. Paper presented at the Group Health Association of America conference, Los Angeles, California, June.
41.
Heinen, L. , E. Peterson, K. Pion, and S. Leatherman. 1993. Quality evaluation in a managed care system Comparative data to assess health plan performance. Managed Care Quarterly1(1): 62-76.
42.
Herrle, G.1992. Physician compensation in the era of managed care. Medical Group Management JournalNovember/December:8-9.
43.
Hillman, A.1987. Financial incentives for physicians in HMOs. New England Journal of Medicine317(27): 1743-1748.
44.
Hillman, A.1991. Managing the physician: Rules vs. incentives. Health AffairsWinter:138-146.
45.
Hillman, A. , W. P. Welch, and M. Pauly. 1992. Contractual arrangements between HMOs and primary care physicians: Three-tiered HMOs and risk pools. Medical Care30(2): 136-148.
46.
HMO MD incentive rules proposed with risk thresholds . Managed Care WeekJanuary 4, p. 1.
47.
Hoy, E. , R. Curtis, and T. Rice. 1991. Change and growth in managed care. Health Affairs10(4): 18-36.
48.
Hurley, R. , D. Freund, and J. Paul. 1993. Managed care in Medicaid: Lessons for policy and program design. Ann Arbor, MI: Health Administration Press.
49.
Iglehart, J. K.1994a. The struggle between managed care and fee-for service practice. New England Journal of Medicine331(1): 63-67.
50.
Iglehart, J. K.1994b. Physicians and the growth of managed care. New England Journal of Medicine331(17): 1167-1171.
51.
Jacobs, M. , and P. Mott. 1987. Physician characteristics and training emphasis considered desirable by leaders of HMOs. Journal of Medical Education62(September): 725-731.
52.
Kongstvedt, P.1993. Primary care in closed panels. In The managed care handbook, edited by Peter Kongstvedt. Gaithersburg, MD: Aspen.
53.
Kopit, W. , and M. Lutes. 1993. Legal issues and antitrust considerations in the establishment of credentialing and other selection criteria. In The managed care handbook edited by Peter Kongstevedt. Gaithersburg, MD: Aspen.
54.
Korenchuk, K.1991. Negotiating and analyzing managed care contracts. Medical Group Management Journal38(1): 17-18, 20-23.
55.
Kouba, D.1991. Primary care providers: Managing today's prepaid risk. Medical Group Management JournalJanuary/February:37-40.
56.
Kretz, S.1991. Quality focused contracting for specialized managed care services. AAPPO JournalJune/July:15-21.
57.
Langwell, K. , N. Carlton, and G. Swearingen. 1989. Industry profile: An in-depth look at Medicare PPO applicants. Princeton, NJ: Mathematica Policy Research.
58.
Lazarus, S. , M. Krill, D. Gans, and A. Bergstrom. 1989. Physician productivity measurement and comparison. Journal of Ambulatory Care Management12(1): 38-51.
59.
Lipsitz, D.1993. A physician incentive compensation program in a staff model HMO. HMO Practice7(2): 82-87.
60.
Lutes, M. , and D. Hastings. 1993. Regulatory and legal influences on managed care. In Making managed healthcare work, edited by Peter Boland. Gaithersburg, MD: Aspen.
61.
Marion Merrell Dow . 1993. Managed Care Digest 8 (PPO ed.). Kansas City, MO: Marion Merrell Dow.
62.
McGuirk-Porell, M. , G. Goldberg, D. Goldin, G. Lenhart, N. Ober, and R. Bizier. 1991. A performance-based quality evaluation system for preferred provider organizations. Quality Review BulletinNovember:365-373.
63.
Miller, R. , and H. Luft. 1991. Perspective: Diversity and transition in health insurance plans. Health Affairs10(4): 37-47.
64.
Montague, J.1993. Straight talk: Doctor-driven systems tell how they've gained physician allies. Hospitals and Health NetworksJuly 5, p. 22-27.
65.
Morain, C.1992. HMOs try to measure (and reward) "doctor quality"Medical EonmicsApril 6, p. 206-215.
66.
More employees demand HMOs get NCQA accreditation . 1993. Managed Care WeekJuly 26, p. 3.
67.
Morreim, E. H.1991. Gaming the system: Dodging the rules, ruling the dodgers. Archives of Internal Medicine151(March): 443-447.
68.
Murray, D.1992. Managed care: The payoffs keep getting bigger. Medical EconomicsDecember 7, p. 124-134.
69.
Nelson, S. , K. Lanywell, R. Brown, B. Brown, N. Carlton, and G. Swearingen. 1990. Organizational and operational characteristics of TEFRA HMOs/CMPs. Princeton, NJ: Mathematica Policy Research.
70.
Ogden, D.1993. Physician/hospital organizations in managed care contracting. Medical Group Management JournalMay/June:12-17.
71.
O'Kane, M.1993. Outside accreditation of managed care plans. In The managed care handbook, edited by Peter Kongstvedt. Gaithersburg, MD: Aspen.
72.
Pauly, M. , A. Hillman, and J. Kerstein. 1990. Managing physician incentives in managed care: The role of for-profit ownership. Medical Care28(11): 1013-1024.
Physician Payment Review Commission1993. Use of the Medicarefee schedule by other payers. Annual report to Congress. Washington, DC: Physician Payment Review Commission.
Schlackman, N.1991. The quality care cydle. Quality Review Bulletin17(11): 360-364.
77.
Schlackman, N.1993. Evolution of the quality based compensation model: The third generation. American College of Medical Quality8(2): 103-110.
78.
Shouldice, R.1987. Negotiating with alternative delivery systems. Medical Group Management Journal34(1): 9-11.
79.
Shortell, S. M. , R. R. Gillies, and D. A. Anderson. 1994. The new world of managed care: Creating organized delivery systems. Health Affairs Wimter.46-64.
80.
Smillie, J. G.1991. Can physicians manage the quality and costs of health care: The story of the Permanente Medical Group. New York: McGraw-Hill.
81.
Somers, A. R. , ed. 1971. The Kaiser-Permanente Medical Care Program A symposium. New York: Commonwealth Fund.
82.
Starr, P.1982. The social transportation ofAmerican medicine. New York: Basic Books.
83.
Sullivan, C. , M. Miller, R. Feldman, and B. Dowd. 1992. Employer sponsored health insurance in 1991. Health AffairsWinter:172-186.
84.
The Inter Study . 1994. Competitive Edge3(2): 34-38.
85.
Traska, M.1988. AMCRA: HMOs confused about gatekeeper's role. Hospitals62(15): 40.
86.
United States Congress, Office of Technology Assessment . 1994. Identifying health technologies that work Searching for evidence. Washington, DC: Office of Technology Assessment.
87.
U.S. Department of Health and Human Services . 1990. Study of incentive arrangements offred byHMOs and CMPs to physicians. Washington, DC: Department of Health and Human Services.
88.
Weiner, J.1993. Razing a tower of Babel: A taxonomy for managed care and health insurance plans. Journal of Health Politics, Policy, and Law18(1): 75-104.
89.
Welch, W. P. , A. Hillman, and M. V. Pauly. 1990. Toward new typologies for HMOs. Milbank Quarterly68(2): 221-243.
90.
Wnickoff, R. N. , K. Coltin, M. Morgan, R. Buxbaum, and O. Bamett. 1984. Improving physician performance through peer comparison feedback. Medical Care22:527-534.
91.
Winslow, R. , and E. Felsenthal. 1993. Physicians fight back as insurers cut them from health networks. Wall Street JournalDecember 30, p. A1.
92.
Zalta, E.1993. Provider selection standards as a quality indicator. Managed Care Quarterly1(1): 53-61.
