American College of Physicians: Internal Medicine — Doctors for Adults ®

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Strategies to talk about managed care conflicts

From the September 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Ingrid Palmer

BOSTON—A 27-year-old woman comes to you complaining of fatigue that has lasted two months. Because she has a friend who experienced similar symptoms and was ultimately diagnosed with multiple sclerosis, she requests an MRI to rule out the possibility that she has the condition. Her physical exam and history are normal, however, and she belongs to a health plan that gives bonuses for avoiding costly tests like MRI. What do you tell the patient?

At the Society of General Internal Medicine's (SGIM) annual meeting last spring, physicians met in small groups to discuss this scenario and others like it. The session, "Responding to Patients' Concerns About Managed Care Conflicts of Interest," addressed the problems that managed care incentives are injecting into the doctor-patient relationship.

Panelist Thomas H. Gallagher, ACP-ASIM Member, assistant professor of medicine at Washington University in St. Louis, said that while patients appreciate managed care's ability to drive down costs and increase preventive services, negative perceptions still "far outweigh the positives." He explained that patients, for example, worry that doctors won't order expensive tests or discuss all available care options if some are too costly.

A recent poll by the Kaiser Family Foundation found that 58% of consumers said they worry that if they become ill, their health plan will be more concerned about the cost of care than about providing the best treatment. "This anxiety among patients is spilling over into the doctor-patient relationship," Dr. Gallagher explained.

Similarly, many consumers worry that their care suffers when health plans give incentives or bonuses to doctors to keep costs down. In the Kaiser poll, 72% of patients said that giving doctors bonuses for keeping costs down was a bad idea, 65% said a bonus would lower their trust in their doctor and 79% said they would choose a plan with no bonus structure. Consumers in the poll also said they should be told whether their doctor receives a bonus without having to ask. (Doctors at the session said that patients rarely, if ever, ask them about bonuses.)

Physicians may dislike managed care just as much as consumers, but they are often put in the difficult position of having to defend health plans to patients. "Many times you end up having to explain to patients what's not covered in their insurance plan, even though it might not be logical to you," said panelist Wendy S. Levinson, FACP, professor of medicine at the University of Chicago.

So what can physicians do? In discussing the above scenario and others like it, physicians at the SGIM meeting identified several ways to explain why an MRI is not warranted. One group of physicians suggested telling the patient that if she wanted a MRI for added peace of mind, she could pay for the test herself. Another group advocated explaining in detail why more tests aren't needed based on her medical history and physical exam. Several physicians also mentioned the option of being forthright about the payment structure of the patient's insurance plan.

Drs. Gallagher and Levinson presented the following additional tips to talk to patients who express concerns about managed care:

Give the facts. Physicians can give patients the straight facts about their illness, treatment and managed care options without offering any commentary on the situation.

Establish a common enemy. "We're stuck in this situation with you" is a phrase that you can use. Doctors can be forthright with patients about the financial difficulties they face under managed care and let the patients know that "we aren't any happier about it than you are."

"Trust me." In this scenario, you ask patients to trust your decision and/or rely on your years of experience in the field. You might even remind them that "I've been doing this for a long time ... "

Dig a little deeper. You can try prodding patients to get at their real concerns by asking, "What is it that bothers you about this situation?" or "What are you really worried about?" Some physicians in the audience warned, however, that patients may view this tactic as avoiding the financial issue.

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