Jan. 13, 2000 (Atlanta) -- The future of managed care in the U.S. will belong to companies that can assure both easy access to care and enduring doctor-patient relationships -- but that care probably won't be delivered in a clinic-like HMO setting. That's what a new study suggests, after surveying more than 6,000 Massachusetts state employees enrolled in 15 different health care plans. The research appears in the latest issue of the American Medical Association journal Archives of Internal Medicine.
"We studied five different models of managed care," says Dana Gelb Safran, ScD, director of The Health Institute at New England Medical Center in Boston. "For simplicity, I like to describe them as open vs. closed systems." Safran says the differentiation has mainly to do with where patients see the doctor -- in the case of open systems, it's in a private office under a contract with a managed care provider. With closed systems, the visit occurs at a managed care facility.
"We studied 11 features of primary care that patients are in the best position to report about," Safran says, "including access to care, continuity with the doctor, and the quality of the interpersonal relationship with the doctor."
"What we found in summary is that the open model of managed care works better on every level than the closed models of managed care," Safran says. The primary reason could be described as better customer service -- on the part of the doctor. "When the responsibility for building and maintaining a strong and sustained relationship remains squarely with the doctor, then they perform better because they know it's their responsibility to see to everything about the patient experience," Safran says. "[Whereas] when doctors work for health plans, they may come to see much of that as the health plan's responsibility."
For this reason, Safran says, the market share for open-model providers is steadily increasing -- and now some traditionally closed-system providers are offering open-model options. "Mostly, the name of the game for Americans is choice, and open models cater to that," she says.
The problem is that consumers mistakenly equate choice with quality, says Beau Carter, executive director of the Integrated Healthcare Association in Walnut Park, Calif. Integrated Healthcare Association is an organization which represents the interests of health care plans, providers, and others involved in the managed care industry in California. "Choice doesn't necessarily mean you get better quality, but it's become a surrogate for quality," he says. In fact, Carter argues that health care plans which are excessively open-ended can mean less quality, because care is then more difficult to manage.
On the other hand, Carter agrees that the "Mother may I?" model of health care -- in which every decision, every expenditure is tightly controlled by the managed care company -- isn't necessarily the answer, either, which is why it's going out of style. "Physicians and consumers alike don't like to be told that this surgery is unnecessary or it's not necessary for that extra battery of tests. ... All that stuff makes people cranky."
In fact, Carter says most of his association's members would likely agree that having physician groups in charge of making health care decisions is probably the best way to go -- but says that type of system can potentially get out of hand. "Some degree of choice and open access makes sense," he says. "The danger is ... we'll wind up with overtreatment."
Not everyone agrees: "You're medically-legally liable," says W.C. Williams, MD, senior vice-president of the National Association of Managed Care Physicians. "So most of my colleagues do what's medically appropriate anyway. That's what we've been taught and that's how we treat patients."
- An open system of managed care, in which a private physician's office works under contract with a managed care provider, works better than a closed system, or managed care facility, according to a new study.
- Consumers rated the open model better in access to care, continuity with the doctor, and quality of interpersonal relationship with the doctor.
- Researchers say the primary explanation is that doctors in the open model provide better customer service because they are solely responsible for the doctor-patient relationship.