Resolving disagreements in the patient-physician relationship - Tools for improving communication in managed care

Managed care uses financial incentives and restrictions on tests and proced ures to attempt to influence physician decision making and limit costs. Inc reasingly, the public is questioning whether physicians are truly making de cisions based on the patient's best interest or are unduly influenced by ec onomic incentives. These circumstances lead to the potential for disagreeme nts and conflict in the patient-physician relationship. We convened a group of individuals in October 1998, including patient representatives, leaders from health care organizations, practicing physicians, communication exper ts, and medical ethicists, to articulate the types of disagreements emergin g in the patient-physician relationship as a result of managed care. We add ressed 3 specific scenarios physicians may encounter, including allocation, illustrated by a patient who is referred to a different ophthalmologist ba sed on a new arrangement in the physician's group; access, illustrated by a patient who wishes to see his own physician for a same-day visit rather th an a nurse specialist; and financial incentives, illustrated by a patient w ho expects to have a test performed and a physician who does not believe th e test is necessary but is afraid the patient will think the physician is n ot ordering the test because of financial incentives. Using these scenarios , we suggest communication strategies that physicians can use to decrease t he potential for disagreements. In addition, we propose strategies that hea lth plans or physician groups can use to alleviate or resolve these disagre ements.