Medicine And Books

Promise and Performance in Managed Care: The Prepaid Group Practice Model

BMJ 1995; 310 doi: (Published 15 April 1995) Cite this as: BMJ 1995;310:1017
  1. Graham Rich

    Donald K Freeborn, Clyde R Pope Johns Hopkins University Press, pp 169 ISBN 0 8018 4819 9

    The prepaid group practice is but one of the various systems of financing and delivering health care that make up the managed care industry in the United States. Most definitions of managed care include some reference to the use of contracts with selected physicians and hospitals that provide comprehensive health care services to members for a monthly premium. It usually means that doctors agree to some form of quality control and minor restrictions on clinical freedom and accept some financial risk. There are extra costs for patients who choose to go to a doctor outside the health plan. Overall, managed care offers an incentive for doctors to balance the needs of individual patients with the cost of care, much as general practice fundholding does in Britain.

    In 1994 a great deal of the debate over reform of health care in the United States centred on the need to regulate the market to promote competition among plans on the basis of cost and quality rather than on the ability to select the most healthy people. Managed care was expected to have a key role in improving access to quality health care. However, the complexity of proposals, a poor understanding of managed care, and millions of dollars' worth of advertisements helped to persuade voters against reform. Many doctors remain concerned that managed care limits professional autonomy and reduces consumers' choice of doctor. The authors rely on extensive reference to published reports on the benefits of managed care to put their own data from Kaiser Permanente north west region into the context of reform.

    Much of the discussion relies on a detailed examination of patients' satisfaction, measures of access, and doctors' satisfaction. The Kaiser Permanente group practice has over 20 years' experience of studying patients' satisfaction through annual postal surveys and, more recently, random sampling of people attending medical offices. The greatest satisfaction was with cost, coverage, and the perceived technical quality of care while there was some dissatisfaction with the process and delay in getting an appointment. Doctors' satisfaction is thought to influence patients' satisfaction, referral rates, prescribing patterns, and ultimately loss of membership and doctors. How all the information is used by the practice to improve or modify services is not described.

    A final section concentrates on the future of managed care, which necessarily touches on the challenges facing the entire system, not least the need to demonstrate quality based on outcomes. The book has particular appeal for business leaders who are attempting to reduce their exposure to the spiralling costs of fee for service insurance, which encourages doctors to do more regardless of appropriateness. As policy-makers gear up for a year when managed care is proposed as a way of improving cost effective care for elderly people in Medicare and for poor people in Medicaid the book should act as a useful resource in its defence. Meanwhile, Britain can learn from the need to recognise the importance of doctors' satisfaction with patient load, referral procedures, and ability to influence the work environment.—GRAHAM RICH, senior health policy analyst, Jackson Hole Group, Wyoming, USA

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