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Introduction to Health Services Research : A Self-Study Course
Module 2: Brief History of Health Services Research (Page 31 of 40)
The Impact of Health Care Reform on Managed Care, Large Employers and Physicians
Health Care Reform Still Strong
While most people today doubt that health care reform moves in the direction of universal coverage and access for all, the managed care model has reached new populations, including Medicare and Medicaid.
HMO Growth
With the managed care industry growth during the 1990s, attention in health services research turned to outcomes research and performance measurement.
Large employers, the purchasers of managed care plans for their employees, wanted to measure the value of their insurance package. They wanted to guarantee that the insurance plans were providing the services their employees needed at a cost that was affordable.
States began creating managed care plans for the uninsured which further increased the number of enrollees.
(See National Committee for Quality Assurance (NCQA) in Module 3 for more information on HMO quality)
Physician Credentialing
Managed care organizations have an interest in assessing the performance of the physicians they employ or with whom they contract.
Managed care organizations have an interest in assessing the performance of the physicians they employ or with whom they contract. Therefore, the physician's utilization of medical services has become a huge issue, and physician economic credentialing (measuring the physician's use of medical resources compared to similar physicians) has gone from being a new area of assessment to accepted practice.
Tensions Build
Physician credentialing creates a tremendous tension between many players in health care.
Physicians express concern that they are losing the responsibility to make clinical decisions for their patients and are valued more for their cost savings performance.
HMOs Impose "Gag Rules" on Physicians
Some managed care organizations imposed "gag rules" on physicians that prohibited them from speaking against the organization to their patients. Others hold physicians financially accountable for the over-utilization of medical services.
Physicians Angered by Changes
This lack of autonomy and threatened control over earnings have angered many physician groups. Many physicians came to regard practice guidelines and outcomes research as a threat to the physician-patient relationship.
View Key Projects and Milestones in Health Services Research.
Discussion Questions
- It says above that physicians are concerned that they are losing the responsibility to make clinical decisions for their patients and are valued more for their cost savings performance. Is this true? What evidence have you seen for or against this concern?
- How successful have managed care organizations been in assessing the performance of the physicians they employ or with whom they contract?
- How has physicians' utilization of medical services and physician economic credentialing affected physicians themselves?
- How do we know that health care reform is still strong as stated in the first sentence above?
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