Clinicians as advocates: An exploratory study of responses to managed care by mental health professionals

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Abstract

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.

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References

  1. 1.
    Eisenberg JM.Doctor's Decisions and the Cost of Medical Care. Ann Arbor, MI: Health Administration Press; 1986.Google Scholar
  2. 2.
    Gold MR, Hurley R, Lake T, et al.Arrangements between Managed Care Plans and Physicians: Results from a 1994 Survey of Managed Care Plans. Washington, DC: Physician Payment Review Commission; 1995. Selected External Research Series, No. 3.Google Scholar
  3. 3.
    Hoy E, Curtis R, Rice T. Change and growth in managed care.Health Affairs. 1991;10(1):18–36.Google Scholar
  4. 4.
    Wolff N, Schlesinger M. Risk, motives and styles of utilization review: a cross-condition comparison.Social Science and Medicine. 1998;47(7):911–926.Google Scholar
  5. 5.
    Clancy CM, Brody H. Managed care: Jekyll or Hyde?Journal of the American Medical Association. 1995;273:338–339.Google Scholar
  6. 6.
    Newhouse JP.Free for All? Lessons from the RAND Health Insurance Experiment. Cambridge, MA: Harvard University Press; 1993.Google Scholar
  7. 7.
    Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource use among medical specialties and systems of care. Results from the medical outcomes study.Journal of the American Medical Association. 1992;267(12):1624–1630.Google Scholar
  8. 8.
    Rubin HR, Rogers WH, Kahn K, et al. Watching the doctor-watchers: how well do peer review organization methods detect hospital quality problems?Journal of the American Medical Association. 1992;267(17):2349–2354.Google Scholar
  9. 9.
    Shekelle PG, Kahan JP, Bernstein SJ, et al. The reproducibility of a method to identify the overuse and underuse of medical procedures.New England Journal of Medicine. 1999;338(26):1888–1895.Google Scholar
  10. 10.
    Ayanian JZ, Landrum MB, Normand SL, et al. Rating the appropriateness of coronary angiography—do practicing physicians agree with an expert panel and with each other?New England Journal of Medicine. 1998;338(26):1896–1904.Google Scholar
  11. 11.
    Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians.Journal of the American Medical Association. 1996;275(21):1693–1697.Google Scholar
  12. 12.
    Schlesinger M, Dorwart RA, Epstein SS. Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy.American Journal of Psychiatry. 1996;153(2):256–260.Google Scholar
  13. 13.
    Schlesinger M, Gray B, Perreira K. Medical professionalism under managed care: the pros and cons of utilization review.Health Affairs. 1997;16(1):106–124.Google Scholar
  14. 14.
    Families USA.Hit and Miss: State Managed Care Laws. Washington, DC: Families USA; 1998.Google Scholar
  15. 15.
    Remler DK, Donelan K, Blendon RJ, et al. What do managed care plans do to affect care: results from a survey of physicians.Inquiry. 1997;34(3):196–204.Google Scholar
  16. 16.
    Appelbaum PS. Legal liability and managed care.American Psychologist. 1993;48(3):251–257.Google Scholar
  17. 17.
    Morreim EH. Gaming the system: “dodging the rules, ruling the dodgers.”Archives of Internal Medicine. 1991;151:443–447.Google Scholar
  18. 18.
    Morreim EH. Economic disclosure and economic advocacy: new duties in the medical standard of care.Journal of Legal Medicine. 1991;12:275–329.Google Scholar
  19. 19.
    Iglehart J. Managed care and mental health.New England Journal of Medicine. 1996;334(2):131–133.Google Scholar
  20. 20.
    Essock S, Goldman H. States' embrace of managed mental health care.Health Affairs. 1995;14(3):34–44.Google Scholar
  21. 21.
    Schreter R, Sharfstein S, Schreter C, eds.Allies and Adversaries: The Impact of Managed Care on Mental Health Services. Washington, DC: American Psychiatric Press; 1994.Google Scholar
  22. 22.
    Hodgkin D. The impact of private utilization management on psychiatric care: a review of the literature.Journal of Mental Health Administration. 1991;19:143–157.Google Scholar
  23. 23.
    Tischler GL. Utilization management and the quality of care.Hospital and Community Psychiatry. 1990;41:1099–1102.Google Scholar
  24. 24.
    Hogan MF. Managed public mental healthcare: issues, trends and prospects.American Journal of Managed Care. 1999;5(special issue):71–77.Google Scholar
  25. 25.
    Mechanic D, Schlesinger M, McAlpine D. Management of mental health and substance abuse services: state of the art and early results.Milbank Quarterly. 1995;73(1):19–55.Google Scholar
  26. 26.
    Boyle P, Callahan D. Managed care in mental health: the ethical issues.Health Affairs. 1995;14(3):7–22.Google Scholar
  27. 27.
    Sabin J, Daniels N. Determining “medical necessity” in mental health practice.Hastings Center Report. 1994;24:5–13.Google Scholar
  28. 28.
    Schlesinger M. On the limits of expanding health care reform: chronic care in prepaid settings.Milbank Quarterly. 1986;64:189–215.Google Scholar
  29. 29.
    Burnam MA, Escarce JJ. Equity in managed care for mental disorders.Health Affairs. 1999;18(5):22–31.Google Scholar
  30. 30.
    Emmons D, Chawla A. Physician perceptions of the intrusiveness of utilization review. In:Socioeconomic Characteristics of Medical Practice. Chicago, IL: American Medical Association; 1991:3–8.Google Scholar
  31. 31.
    Schlesinger M. Utilization review and the treatment of mental illness: emerging norms and variabilities. In: Mechanic D, ed.Managed Behavioral Health Care: Current Realities and Future Potential. San Francisco: Jossey Bass; 1998.Google Scholar
  32. 32.
    Schlesinger M, Wynia M, Cummins D. Managed care and psychiatry: some distinctive features and their implications for clinical practice.Harvard Review of Psychiatry. 2000;8:216–230.Google Scholar
  33. 33.
    Zarin DA, West JC, Pincus HA, et al. Characteristics of health plans that treat psychiatric patients.Health Affairs. 1999;18(5):226–236.Google Scholar
  34. 34.
    Mechanic D, McAlpine D. Mission unfulfilled: potholes on the road to mental health parity.Health Affairs. 1999;18(5):7–21.Google Scholar
  35. 35.
    Franks P, Clancy CM, Nutting PA. Gatekeeping revisited: protecting patients from overtreatment.New England Journal of Medicine. 1992;327:424–429.Google Scholar
  36. 36.
    Grosser RC, Vine P. Families as advocates for the mentally ill: a survey of characteristics and service needs.American Journal of Orthopsychiatry. 1991;61:282–290.Google Scholar
  37. 37.
    Scarf M. Keeping secrets.New York Times Magazine, June 16 1996, 38–40.Google Scholar
  38. 38.
    Emanuel E, Goldman L. Protecting patient welfare in managed care: six safeguards.Journal of Health Politics, Policy and Law. 1998;23(4):635–659.Google Scholar
  39. 39.
    Tapay N, Feder J, Dallek G.Protection for Consumers in Managed Care Plans: A Comparison of Medicare, Medicaid and the Private Insurance Market. Menlo Park, CA: Kaiser Family Foundation; 1998.Google Scholar
  40. 40.
    Kaiser Family Foundation.Survey of Physicians and Nurses. Menlo Park, CA: Henry J Kaiser Family Foundation; 1999.Google Scholar
  41. 41.
    Kaiser Family Foundation/Harvard University School of Public Health.Survey of Physicians and Nurses, Summary of Findings and Chart Pack. Available at: www.kff.org/content/1999/1503/PhysiciansNursesSurveyChartPack.pdf. Accessed May 2002.Google Scholar
  42. 42.
    Sage WM. Physicians as advocates.Houston Law Review. 1999;35(5):1529–1630.Google Scholar
  43. 43.
    Ku L, Fisher D. The attitudes of physicians toward health care cost-containment policies.Health Services Research. 1992;25(1):25–42.Google Scholar
  44. 44.
    Annas G. Patients' rights in managed care—exit, voice and choice.New England Journal of Medicine. 1997;337(3):210–215.Google Scholar
  45. 45.
    Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship.Journal of the American Medical Association. 1992;267:2221–2226.Google Scholar
  46. 46.
    Morreim EH.Balancing Act: The New Medical Ethics of Medicine's New Economics. Dordrecht, Netherlands: Kluwer Academic Publishers; 1991.Google Scholar
  47. 47.
    Rodwin MA.Medicine, Money & Moral. Oxford, UK: Oxford University Press; 1993.Google Scholar
  48. 48.
    Daniels N. The ideal advocate and limited resources.Theoretical Medicine. 1987;8:69–80.Google Scholar
  49. 49.
    Council of Ethical and Judicial Affairs. Ethical issues in managed care.Journal of the American Medical Association. 1995;272(4):330–335.Google Scholar
  50. 50.
    Orentlicher D. Physician advocacy for patients under managed care.Journal of Clinical Ethics. 1995;6:333.Google Scholar
  51. 51.
    Schlesinger M. Countervailing agency: a strategy of principled regulation under managed competition.Milbank Quarterly. 1997;75(1):35–87.Google Scholar
  52. 52.
    Scheffler R, Ivey SL. Mental health staffing in managed care organizations.Psychiatric Services. 1998;49(10):1303–1308.Google Scholar
  53. 53.
    Liner RS. Physician deselection: the dynamics of a new threat to the physician-patient relationship.American Journal of Law and Medicine. 1997;23(4):511–537.Google Scholar
  54. 54.
    Steinwachs D, Kasper J, Skinner E.Family Perspectives on Meeting the Needs for Care of Severely Mentally Ill Relatives: A National Survey. Baltimore, MD: Johns Hopkins University School of Hygiene and Public Health; 1992.Google Scholar
  55. 55.
    Uttaro T, Mechanic D. The NAMI consumer survey analysis of unmet needs.Hospital and Community Psychiatry. 1994;45(4):372–374.Google Scholar
  56. 56.
    Hart GL, Wagner E, Pirzada S, et al. Physician staffing ratios in staff-model HMOs: a cautionary tale.Health Affairs. 1997;16(1):55–70.Google Scholar
  57. 57.
    Reinhardt S.Living with Mental Illness: Effects of Professional and Personal Control on Caregiver Burden. New Brunswick, NJ: Rutgers University; 1991. Dissertation.Google Scholar
  58. 58.
    Mechanic D. Managed care and the imperative for a new professional ethic.Health Affairs. 2000;19(5):100–111.Google Scholar

Copyright information

© Association of Behavioral Healthcare Management, NCCBH 2002

Authors and Affiliations

  1. 1.EJ Bloustein School of Planning and Public PolicyUSA
  2. 2.Center for Research on the Organization and Financing of Care for the Severely Mentally IllRutgers UniversityNew BrunswickUSA
  3. 3.Department of Epidemiology and Public HealthYale UniversityUSA
  4. 4.Institute for Health, Health Care Policy and Aging ResearchRutgers UniversityUSA

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