PRESERVING THE PHYSICIAN-PATIENT RELATIONSHIP IN THE ERA OF MANAGED CARE

Even without comprehensive health care reform legislation, the US heal th care system is undergoing significant changes. Probably the most im portant change is the expansion of managed care with significant price competition. One of the major concerns about this change is the effec t of managed care on the physician-patient retationship. To provide a normative standard for evaluating the effect of changes, we need an id eal conception of the physician-patient relationship. This ideal can b e summarized by six C's: choice, competence, communication, compassion , continuity, and (no) conflict of interest. For the 37 million uninsu red Americans there is little chance of realizing the ideal physician- patient relationship, since they lack the choice of practice setting a nd physician, receive care in a rushed atmosphere that undermines comm unication and compassion, and have no continuity of care. While many i nsured Americans may believe they have an ideal physician-patient rela tionship, the relationship is threatened by lack of a regular assessme nt of competence, by financial incentives that undermine good communic ation, and by the persistence of conflict of interest. The shift to ma naged care may improve the choice of practice settings, especially in sections of the country that currently lack managed care; increase cho ice of preventive services; make quality assessments more routine; and improve communication by making greater use of primary care physician s and nonphysician providers. However, the expansion of managed care a nd the imposition of significant cost control have the potential to un dermine all aspects of the ideal physician-patient relationship. Choic e could be restricted by employers and by managed care selection of ph ysicians; poor quality indicators could undermine assessments of compe tence; productivity requirements could eliminate time necessary for co mmunication; changing from one to another managed care plan to secure the lowest costs could produce significant disruption in continuity of care; and use of salary schemes that reward physicians for not using medical services could increase conflict of interest.