The role of managed care and financing in medical practices: how does psychiatry differ from other medical fields?

BACKGROUND: The organization and financing of medical practice has experienced substantial changes during the past decade. Today the majority of individuals with private insurance are enrolled in managed care plans and traditional indemnity insurance is only predominant among Medicare enrollees. At the same time that managed care was growing in general, there was also substantial growth in the number of managed care companies specializing in behavioral health care and separating them out ("carved-out") from other medical care. While it is clear that these changes in managed care penetration and financing arrangements have affected physicians and the way they practice medicine, it is less clear whether there has been a differential effect across physician types.

METHOD: Data are from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1998 and November 1999. To be eligible, physicians had to have completed their medical training (which excludes residents, interns, or fellows), be practicing in the contiguous United States, and be providing direct patient care for at least 20h per week. The total number of completed interviews was 12,304, including 566 psychiatrists, 7,217 primary care physicians, and 4,521 other medical or surgical specialists. Consistent with the previous literature, our analysis is primarily descriptive presenting weighted means and odds ratios from multivariate models.

RESULTS: Psychiatrists are significantly less likely than primary care physicians or other specialists to agree with the statements that clinical decisions in the interest of their patients do not reduce income. Further, in comparison to primary care physicians, psychiatrists are less likely to agree that it is possible to maintain continuing relationships with patients over time that promote the delivery of high quality care and that they have the freedom to make clinical decisions that meet their patients' needs. In contrast to the perceived impacts on practice, psychiatrists tend to work in practices with a lower dependence on managed care than either other specialists or primary care physicians. Regarding individual physician compensation among non-owners, psychiatrists are less likely than other physicians to have their income adjusted based on individual productivity.

CONCLUSIONS: Psychiatrists are more concerned that managed care has a negative impact on patient-provider relationships than other physicians; however, based on the available measures of financing and organization, psychiatrists are less dependent on managed care. This may suggest that other aspects of managed care, such as pre-authorization and gatekeeping, that disproportionately affect specialists are driving psychiatrists' perceptions of the patient-provider relationship.