BY MIKE GOODKIND

Patients fed up with seeking health-plan approval for medical treatments take note: Your doctors dislike it too -- especially independent office practitioners who must deal with several different organizations, according to a Stanford study published Monday in the Archives of Internal Medicine.

Doctors in private practice whose patients belong to a variety of health-maintenance organizations are more dissatisfied than colleagues who work in a staff/group model HMO, where a single administrative structure processes payments and handles other administrative issues, according to the study conducted in San Mateo County. Also, doctors in the staff/group model HMO expressed more confidence that procedures or rules set by review organizations could improve patient care, the researchers found'

"It's a killer. Doctors are fed up with the layers of phone calls, the whole effort they must make to contact multiple managed-care companies to seek approval to care for their patients," said senior author Thomas Raffin, MD, the Colleen and Robert Haas Professor in Medicine and Biomedical Ethics, and co-director of the Stanford Center for Biomedical Ethics.

The report is based on a 1998 survey of doctors in San Mateo County, an affluent area near San Francisco where managed care is common. The survey was sent to doctors affiliated with Kaiser Permanente -- a staff/group HMO -- and doctors in independent, office-based practices. The physicians were asked to evaluate their experiences with HMOs during the previous five years.

Both groups reported similar numbers of hours worked and a similar number of patient encounters by the end of the five-year period, "which would further indicate that the dissatisfaction came from the frustration of dealing with multiple outside review organizations, not the patient experience," Raffin said.

Fifty-six percent of the 113 Kaiser respondents said Kaiser's treatment guidelines were helpful in improving the quality of patient care. In comparison, only 4 percent of the 250 office-based physicians who responded felt HMO guidelines improved care.

The differences were even more dramatic when it came to drug formularies -- the list of effective, low-cost prescriptions insurers want doctors to use. Forty-two percent of the Kaiser doctors said their single, physician-guided formulary made it easier to prescribe medication, contrasted with only 1 percent of their office-based colleagues.

"The take-home message is that physicians feel more satisfied if they find consistency in the ways the financial, prescription and other controls are administered. Unlike their Kaiser counterparts, the office-based physicians had to deal with multiple conflicting referral guidelines and drug formularies that were usually developed without their input," Raffin said.

"This study isn't an argument that group practice, such as Kaiser, is the only way to practice medicine. Rather, it might be a good argument for a single-payer system," Raffin said.

"One of the reasons Kaiser doctors say they are happier is that they are participants. They have more say in what they do," said author Philip R. Alper, MD, an internal medicine/endocrinology practitioner in San Mateo County who was a visiting fellow at the Stanford Center for Biomedical Ethics when the study was conducted. "A system in which many people other than the doctor are managing care is irrational, inefficient and demoralizing."

The researchers noted the office-based physicians generally suffered greater income declines than their Kaiser colleagues during the five years of the survey, but dissatisfaction appeared to be widespread even when this was taken into account, said Raffin.

Other authors of the study are Laurence C. Baker, PhD, assistant professor of health research policy; Sandra R. Wilson, PhD, consulting professor of health research and policy; and medical students Eric L. Chehab and Neethi Panicker.

The study was funded by the Li Ka Shing Foundation Limited, Hong Kong; the Stanford Center for Biomedical Ethics; and the San Mateo County Medical Association.