Open AccessDefining Educational Priorities in Managed Care
Author(s) -
Kerr Eve A.,
Clancy Carolyn M.
Publication year - 1999
Publication title -
journal of general internal medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.746
H-Index - 180
eISSN - 1525-1497
pISSN - 0884-8734
DOI - 10.1046/j.1525-1497.1999.00261.x
Subject(s) - managed care , medicine , capitation , reimbursement , specialty , health care , ambulatory care , referral , family medicine , population , nursing , utilization management , health maintenance , workforce , environmental health , economics , economic growth
The need for cost containment and the movement toward managed care have restructured traditional roles among patients, physicians, and health care organizations. Nationally, nearly 80% of primary care physicians have at least one managed care contract.1 Approximately 45% of primary care physicians and 40% of specialists are employees of health care organizations,2 and about half of all primary care physicians and at least 20% of specialists receive at least part of their reimbursement through capitation.1 Further, 65 million Americans are enrolled in health maintenance organizations, double the number from one decade ago.3 In addition, a multitude of managed care organizations have evolved, with nearly as many acronyms, that take responsibility for coordinating and delivering care to a population of enrollees. Managed care places new responsibilities on physicians, health care organizations, and patients. For primary care physicians, these responsibilities include independently treating patients with a greater variety of chronic and acute conditions in ambulatory settings, formally acting as “gatekeepers” for specialty services and tests, and practicing cost-effectively.4–6 Specialists also have begun practicing in ambulatory settings with an emphasis on cost-effectiveness and are establishing new referral mechanisms as their traditional sources of referrals shift owing to preferred provider listings and HMO regulations.7 Managed care organizations, which extend beyond the traditional health plan or group to organized delivery systems, independent practice associations, and physician-hospital organizations, among others,8 have become responsible not only for delivering care but also for controlling utilization, maintaining and improving the health of their enrolled population, and monitoring quality.9 In some cases, managed care organizations have subsumed responsibilities previously delegated to physicians. Patients have assumed the duties of making informed decisions about which plan to join, understanding in exacting detail what their insurance covers, and navigating the referral system when they need specialty care.