Preserving the Physician-Patient Relationship in the Era of Managed Care

Abstract

Even without comprehensive health care reform legislation, the US health care system is undergoing significant changes. Probably the most important change is the expansion of managed care with significant price competition. One of the major concerns about this change is the effect of managed care on the physician-patient relationship. To provide a normative standard for evaluating the effect of changes, we need an ideal conception of the physician-patient relationship. This ideal can be summarized by six C's: choice, competence, communication, compassion, continuity, and (no) conflict of interest. For the 37 million uninsured Americans there is little chance of realizing the ideal physician-patient relationship, since they lack the choice of practice setting and physician, receive care in a rushed atmosphere that undermines communication and compassion, and have no continuity of care. While many insured Americans may believe they have an ideal physician-patient relationship, the relationship is threatened by lack of a regular assessment of competence, by financial incentives that undermine good communication, and by the persistence of conflict of interest. The shift to managed care may improve the choice of practice settings, especially in sections of the country that currently lack managed care; increase choice of preventive services; make quality assessments more routine; and improve communication by making greater use of primary care physicians and nonphysician providers. However, the expansion of managed care and the imposition of significant cost control have the potential to undermine all aspects of the ideal physician-patient relationship. Choice could be restricted by employers and by managed care selection of physicians; poor quality indicators could undermine assessments of competence; conductivity requirements could eliminate time necessary for communication; changing from one to another managed care plan to secure the lowest costs could produce significant disruption in continuity of care; and use of salary schemes that reward physicians for not using medical services could increase conflict of interest.

Coping Together and Apart: Exploring How Patients and Their Caregivers Manage Terminal Head and Neck Cancer

“…For patients with terminal HNC and their caregivers, doubt in professionals' honesty, competence, and compassion resulted in a lack of perceived support. These characteristics have been suggested to be key components of the doctor-patient relationship (Emanuel & Dubler, 1995).…”

Effective Doctor–Patient Communication: An Updated Examination

“…Doctors have an obligation to uphold patient confidentiality because (a) a patient's personal health information is private and (b) a patient's desire to give relevant information (for diagnosis and treatment purposes) is contingent upon a guarantee of confidentiality (Marsh & Reynard, 2009). Patients with successful doctor-patient interactions trust their doctors and, by the same token, are more inclined to delaying expensive diagnostic exams and accepting watchful waiting-that is, a "wait-and-see" recommendation (Emanuel & Dubler, 1995). With their increased trust in physicians, patients are also more prone to disclosing "potentially stigmatizing information about health-related behaviors and personal feelings" (Mechanic & Schlesinger, 1996, p. 1694.…”

Forced Disruption in Continuity of Primary Care: The Patients' Perspective

“…Continuity of care has been recognized as a major cornerstone of the ideal physician I patient relationship, particularly as it applies to primary care (Ware and Snyder 1975;Gonnella and Herman 1980; Weiss, Ramsey and McWhinney 1982;Weiss and Ramsey 1989;Hjortdahl and Laerum 1992;Emanuel and Dubler 1995). The radically changing landscape of managed care in the United States increasingly limits both patient and physician options for maintaining continuity in the doctor-patient relationship (Woolhandler and Himmelstein 1995).…”