HMOs change physician
habits for all patients, study shows
BY MIKE GOODKIND
Doctors who alter or
reduce their services to meet HMO requirements for their
managed care patients may make the same changes for all
of their patients, according to a Stanford research study
published in the Feb. 3 Journal of the American Medical
Association.
"HMOs are
fundamentally changing the way doctors practice medicine
for all of their patients," said Laurence C. Baker,
PhD, assistant professor of health, research and policy.
"Physicians conditioned to function in a managed
care environment may find themselves treating even
fee-for-service patients with a managed care
mindset," Baker wrote.
Baker's research found
that Medicare fee-for-service expenditures declined in
proportion to increases in market share of HMOs.
Specifically, Medicare paid out less per beneficiary in
those parts of the country where HMOs had the largest
share of the market. Baker said it appears that the
decrease was triggered by a drop in the number and
intensity of services, not necessarily changes in prices.
"For example, if
physicians are told by HMOs that they should never run an
MRI scan on patients on a first visit for certain
symptoms, they may adapt their practice styles so that
they tend to hold off ordering such scans even for
patients whose insurance would pay for such a test on a
first visit," he said.
Baker, a health economist,
speculated that there might be several reasons for this
consistency in behavior:
* Some practitioners find
it too complex and burdensome to keep track of insurance
rules for each patient, "so doctors simply try to
pick the solution that works for most of their patients
and stick to that scenario when they can."
* Physicians often are
philosophically opposed to changing their practices to
conform with how they're being paid. "Many doctors
want to provide care that is roughly consistent across
the patients that they see," he said.
* Physicians may agree
with some of the standards set by HMOs, feeling that the
recommendations are prudent for medical as well as
economic reasons, and should be used for all patients.
* Doctors who do not treat
many HMO patients, but who interact with others who do,
may absorb HMO practice styles from their colleagues who
take care of HMO patients.
Baker also noted that the
availability of services would eventually begin to match
the market. For example, if HMOs refuse to pay for a
certain diagnostic test, that test may be harder for
doctors to find or secure for their patients.
Baker said Medicare was
used for the comparison because it is not directly
influenced by competitive market forces and it does not
subject its patients to the same limitations that most
managed care plans impose.
In his research, Baker
found that the average decline in expenditure per patient
on both parts A (hospitalization insurance) and B
(medical insurance) of Medicare in markets with the
highest HMO penetration was small -- about $34 per
beneficiary on part A in 1994. But he called the decline
"statistically significant," noting that it was
"enough to suggest that we should pay more attention
to the effects managed care can have on non-managed-care
patients." SR
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