![]() ![]() |
![]() ![]() Back in the Driver's Seat: Specialists Regaining AutonomyTracking Report No. 7
Specialists Clinical Autonomy Increased Compared with their primary care colleagues, specialists were less likely during the zenith years of managed care to agree they were free to make clinical decisions that met their patients needs. Responding to regulatory and market pressures in the late 1990s, many health plans began easing restrictions on care and offering broader provider networks, often resulting in fewer controls on the use of medical services, which made it easier for patients to access specialists and for physicians to make referrals for tests and procedures. 2 Between 1997 and 2001, specialists views about patient care changed significantly. They reported having greater clinical autonomy, improved continuity of care with patients and more coordination with PCPs. Over the same period, the proportion of specialists agreeing they could freely make clinical decisions rose by 13 percentage points, from 72.7 percent in 1997 to 85.7 percent in 2001 (see Figure 1). In contrast, the percentage of primary care physicians reporting they could freely make decisions freely remained almost constant at 86 percent between the two surveys. Equal proportions of PCPs and specialists now believe they have clinical autonomy. Specialists sense of increasing clinical autonomy paralleled a rise in their perception that clinical decision making would not affect their incomes. Between 1997 and 2001, the proportion of specialists agreeing they could make clinical decisions in the best interest of patients without affecting their bottom lines rose from 68.6 percent to 79.6 percent, while the corresponding proportion of PCPs reporting clinical autonomy again remained almost constant (see Table 1). The decline in capitated contracting—where managed care organizations pay physicians a fixed sum for each patient per month—probably accounts for a portion of this striking attitude shift among specialists, which was not seen among PCPs. Among those specialists with managed care contracts, the proportion deriving at least some revenue from capitation declined from 45 percent to 36.4 percent. 3 PCPs also experienced a reduction in capitation, but that decline was not as steep. In addition, restrictions on prior authorizations would likely have affected specialists incomes more, since they are the ones generally performing the procedures subject to authorization. Responding to regulatory and market pressures in the late 1990s, many health plans began easing restrictions on care and offering broader provider networks, making it easier for patients to access specialists. Figure 1 Physicians Agreeing They Have the "Freedom to Make Clinical Decisions that Meet Patients Needs" ![]() * Change from previous period is statistically significant at p<.05. # Change from 1997 to 2001 is statistically significant at p<.05. Source: HSC Community Tracking Study Physician Survey
Back to TopDiffering Views on Continuity of Care, Communication While specialists consistently reported more difficulty maintaining continuing relationships with their patients than did PCPs between 1997 and 2001, there was a 15.2 point increase in the percentage of specialists who agreed they had continuity with their patients (from 57.9% to 73.1%). In contrast, there was little change in PCPs views on continuing relationships during this period. Although specialists are still less likely than PCPs to report continuity of care with patients, the difference between them has decreased from 20 percentage points to about 4 percentage points. Many health plans no longer require referrals for specialty care and now allow direct access, likely making it easier for patients to see specialists, which leads to better continuity of specialist care. Other countervailing trends have appeared between specialists and PCPs. During each survey period, PCPs were more likely than specialists to believe that communication between specialists and PCPs was sufficient to ensure high-quality care. However, the percentage of PCPs who reported adequate communication declined between 1997 and 2001, while the percentage among specialists increased. Fewer managed care restrictions on direct access to specialists that allow patients to bypass PCPs may help explain these divergent trends. Back to TopRole of Managed Care Involvement Comparing physicians in the top third of managed care revenue with those in the bottom third 5 reveals how views among physicians most heavily involved with managed care differ from the views of those with the least managed care participation. Specialists reported greater ability in 2001 than in 1997 to make decisions in the interest of their patients without reducing their incomes, regardless of their current participation in managed care. In 1997, 66.9 percent of specialists with the highest managed care revenue reported that decisions about patient care did not affect income negatively, compared with 72.8 percent of specialists with the lowest managed care participation. This 6 percentage point gap declined to 2 percentage points by 2001, suggesting that managed care involvement is much less important to specialists clinical autonomy. In contrast, PCPs with the highest and lowest involvement of managed care had a gap of 7 percentage points in 1997, which widened to 8 percentage points by 2001. 6Specialists with the most managed care reported a dramatic improvement in their ability to maintain relationships with their patients. The proportion of specialists with the highest managed care revenues agreeing they can maintain relationships increased from 53.9 percent to 71.2 percent between 1997 and 2001. Specialists with the lowest managed care revenues experienced less change (from 66.9% to 76.6%). In contrast, the proportion of PCPs with the highest or lowest managed care revenues who reported continuity with their patients did not change over the same period. Seventy-four percent of PCPs with high managed care revenues, and about 82 percent of PCPs with low managed care revenues, reported continuing relationships with patients in both 1997 and 2001. One departure from the differing perceptions of PCPs and specialists is the relationship between lower managed care participation and physicians having adequate time with their patients. Both PCPs and specialists with the lowest managed care revenues are more likely to report having adequate time with their patients than are their colleagues with high managed care revenues. On average, physicians with low managed care participation were 10 to 12 percentage points higher in terms of reporting enough time with patients than were physicians with high managed care participation. Moreover, both categories of physicians reported a decline in adequate time with their patients. In 1997, 74 percent of PCPs and 79 percent of specialists with low managed care participation reported having adequate time, compared to 65 percent of PCPs and 74 percent of specialists in 2001. Generally, physicians with lower levels of managed care revenue reported more autonomy and continuity with patients compared with physicians with higher levels of managed care participation. Back to TopImplications of More Specialist Autonomy Society will continue to search for ways to improve physicians abilities as professionals to provide better patient care while limiting the costs of these steps. It is increasingly clear that patients and specialists prefer looser managed care. It is less clear, however, that patients, employers and taxpayers are willing to pay for completely unmanaged health care. Therefore, the current balance among access, specialist autonomy and cost is likely to shift again soon. The current balance among access, specialist autonomy and cost is likely to shift again soon. Back to TopData Source Back to TopNotes
Back to TopSupplementary Tables Supplementary Table
1: Clinical Decision Making, Time with Patients and Continuity and Coordination
Among Physicians with Low or High Participation in Managed Care TRACKING REPORTS are published by the Center for Studying Health System Change. ![]() |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
![]() |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||