THE CORPORATE PRACTICE OF MEDICINE AND LONG-TERM HEALTH STATUS: FUTURE RESEARCH ISSUES.

Are the profit needs of corporate America and long-term health status of individuals and society inconsistent? This work represents a conceptual exploration of the general proposition that decisions made in a corporate environment are more likely to be made in the interest of profitability and Wall Street performance rather than individual health status. In this theoretical examination, the term corporate practice of medicine refers to any provision of healthcare services for a profit. The general focus of the work is on corporate behavior associated with decision-making in healthcare corporations. The term also includes competitive managed care entities like Health Maintenance Organizations (HMOs), Point of Service Plans (POS), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Individual Practice Associations (IPAs).

The point of this line of inquiry is to obtain more insight on possible societal issues related to a competitive environment in which healthcare is traded like any other marketable service. For example, one reality with which healthcare policy stakeholders are becoming increasingly familiar, and with which consumers of healthcare services are becoming increasingly wary, is that in a competitive, managed-care environment corporate healthcare providers are rewarded for providing less care rather than more care. That is, financial incentives to over-treat patients have been replaced by financial incentives to under-treat patients.(1)

This paper focuses on a review of journal-based literature to bring insight into preliminary research questions. Three working research questions were fashioned to encourage examination of a broad literature base sensitive to the central focus on corporate, for-profit provider behavior and long-term health status. The purpose of this approach is to facilitate the future efforts by others interested in pursing this research area. The initial working research questions that emerge from this inquiry approach include: (1) what are examples of physician-patient relationship issues related to the corporate practice of medicine that might be inconsistent with long-term health status? Selective literature responsive to this question appears to share the common theme of Physician-Patient Relationship Issues; (2) what are examples of ways that managed care plans restrict access to healthcare services that impact long-term health status? Literature in this area is framed by the concept of Ways to Restrict Access; (3) what are examples of current methodologies and systems used to evaluate health status outcomes? Ways to Measure Health Status seems to capture the thrust of the essentially technical literature responsive to this question. In this regard, the current measurement literature appears to focus most on identification of current health status measures appropriate for providers beginning to assess the impact of their services on health status.

Based on the review of the literature, this work concludes with specific research questions in each of these areas. Readers will hopefully recognize that the nature of the task of organizing separate streams of literature may limit the extent to which each stream may appear to be related to the other. Thus, while sections one and two, concerning the first two organizing questions appear to be related, the third question on measurement issues, while nonetheless critical to the purpose of the paper, may appear to be less related to the flow of the paper in the first two areas.

BACKGROUND

The passage of the Health Maintenance Organization Act of 1973 signaled the transformation of the American healthcare delivery process. The development of the corporate, for-profit, managed care model since 1973 has focused primarily on market growth and cost control. Few societal protection mechanisms have accompanied the corporate model to serve as standards of profit-making reasonableness. Thus, the existing environment is characterized by a scarcity of laws and regulations to help insure that patient clinical interests are best served by corporate, for-profit behavior. Importantly, socially responsible corporate outcome measures need to be identified, debated, and tested preparatory to development of healthcare policies relative to the corporate practice model.

A consistent stream of literature supports the contention that fee-for-service medicine dominated the healthcare world prior to managed health and that physicians were the sole managers of patient care (Kassirer 1995). For example, according to some researchers (Fowles et al. 1996), only 37 HMOs were listed with an enrollment between 3 and 3.6 million people by the end of the 1970s. By 1994, however, this number was an astronomical 574 HMOs accounting for more than 51 million people. This turn towards corporate medicine brings criticism as well. Managed healthcare is not ail-inclusive, and certainly brings its share of problems. In 1996 alone, over 1,000 pieces of legislation and 56 laws in 35 states were passed with the intention of weakening managed tare groups like HMOs (Bodenheimer 1996). As of 1997, 18 states passed legislation, generally referred to as a patient's bill of rights, that prohibited such clauses (Schuyler 1997).

Since managed care integrates the cost of healthcare with the allocation of services, both the physician and the patient are controlled by policies established and enforced by the managed care group (Rodwin 1995). These policies are developed and implemented by the administrators in the managed care group. In the basic model, a primary care physician acts as a "gatekeeper" opening or keeping the door closed to ancillary services or specialists (Inglehart 1995). The intent is to keep medical costs at a minimum, while providing quality healthcare. One researcher described the managed care model dilemma as one in which physicians are expected to provide a wide range of services, recommend the best treatments, and improve patients' quality of life. On the other hand, to keep expenses to a minimum they must limit the use of services, increase efficiency, shorten the time spent with each patient, and use specialists sparingly (Kassirer 1995). One recent study (Grumbach 1999).reported that one-quarter of the primary care physicians surveyed believed they were doing more work than they should be doing

Generally, this work seeks to increase awareness of the extent to which the corporate practice of medicine may negatively impact one's prospects for long-term health status. For example, from a profitability perspective, corporate choices to increase the frequency of low-cost patient encounters, as opposed to high-cost encounters frequently associated with chronic conditions, makes perfect business sense. This is so even if more costly services, such as those of a specialist, might be more in the patient's long-term clinical interest. Also from a profitability perspective, the decision by a managed care provider to minimize referrals for cardiac rehabilitation for post-surgical CABG patients seems prudent if the managed care provider is only rewarded for generating corporate profit.

LITERATURE REVIEW

Physician-Patient Relationship Issues

This work focuses on learning more about the possibility that corporate medicine's need for profit may drive physicians to sacrifice positive health assessment in order to abide by the rules and regulations established by the managed care group. A thorough literature review has reinforced the difficulty in defining what specifically generates positive health status. At this point in time, the concept of measuring organizational effectiveness in terms of positive assessments of health status appears to be a relatively new notion in the corporate accountability context suggested in this paper. According to Emanuel and Dubler (1995), the concept also remains a gray area within the medical arena with many corporations avoiding commitment to a central standard. However, in general, the literature strongly supports the central idea that, of the factors related to positive assessments of health status, one that needs much more examination relative to for-profit organizational output is the physician-patient relationship.

In this regard, Emanuel and Dubler's work is helpful in providing a framework for evaluating aspects of the physician-patient relationship that may be jeopardized by the corporate practice of medicine. These authors propose six qualities for a successful physician-patient relationship. The six qualities are: patient choice; (no) conflict of interest; competence; communication; compassion; and, continuity of care. If all these qualities are present, according to these authors, a trusting relationship is established between the physician and patient and the resultant successful physician-patient relationship is more likely to culminate in an improved quality of care and patient satisfaction. In this work, Emanuel and Dubler's six qualities are reframed as trust, quality, and satisfaction.

Trust

Patient choice is severely limited in managed care groups. For example, when a patient sees a primary care physician in a managed care group, additional care by a specialist will not be authorized unless, the primary care physician refers the patient. However, these so-called "gatekeeping" physicians are encouraged and expected to keep expenses to a minimum. One way to do this is by limiting services. Trust between physician and patient is threatened (Robinson & Casalino 1995). Six states have passed legislation allowing patients to seek limited specialist care directly. Bodenheimer (1996) reports that Arizona and Wyoming have passed laws requiring managed care groups to release policies that govern physician incentive programs which decrease referrals to specialists or withhold clinical services.

Managed care groups reflect an inherent conflict of interest. While physicians pledge to take care of their enrollees, their financial success depends on doing as little for them as possible (Angell & Kassirer 1996). Incentives are offered for many providers who keep the cost of treatment down. As a punitive action, some HMO's can terminate physician employment without any substantiated flaw in practice. If the provider spends too much money on ancillary tests and procedures, their job could be lost. This problem is sufficiently grave that nine states in 1995 and 1996 passed legislation protecting physicians from "without just cause" termination of employment (Bodenheimer 1996). Physicians need a practice environment where their employment is not threatened for ordering what they feel is the most appropriate treatment for their patients. Physicians are forced into a numbers game to make managed care groups more productive. Time allotted for patients is reduced. Effective communication between a physician and patient takes time. Thus, when the structure in which the physician-patient encounter takes place restricts communication, this flaw frustrates a trusting relationship with the patient (Emanuel & Dubler 1995). Further, in corporate medicine, non-physician case managers usually coordinate patient care. Thus, case management also creates conflict for physicians (Rodwin 1995).

Quality

The corporate managed care model pressures primary care physicians to provide medical care that might be out of their realm. This pressure stains the physician competence level. Much litigation has resulted from this issue. For example, according to Bodenheimer, (1996), a managed care group in California was sued for 2.9 million dollars for delaying referral of a patient with "inoperable sigmoid carcinoma" for eleven weeks. Quality assurance measurements can reinforce this point more by looking at the focus of managed care organizations. The number one area for quality assurance monitoring and evaluation is overuse of services (Kerr et al. 1996).

Successful communication is paramount in the physician-patient relationship. A patient must divulge an accurate medical history so the physician can analyze the medical problem at hand. Patients want more from physicians than a simple service transaction. They demand time, information, explanation, empathy, open communication, and cooperative decision making. To provide appropriate long-term healthcare, a trusting relationship along with effective communication is required. Kaplan et al. (1989) conducted a study in which they looked at the effects of increasing patient-physician communication on the outcomes of chronic disease. Their study found that more patient control, communication, affect, and more information provided by the physician in response to information seeking by the patient were related to better health. Managed care emphasizes preventative care. However, patients usually do not go to physicians when they are healthy, usually illness explains their care seeking behavior. Since these plans do not concentrate on illness, their ability to handle complicated cases is vastly reduced The resulting lack of patient autonomy, combined with communication deceptions, drastically reduces quality of care (Angell & Kassirer 1996).

Another aspect of communication that appears to impact development of a trusting physician-patient relationship, besides time allotted for patients, is the physician's willingness to honestly discuss treatment options (Levinson et al. 1999). Managed care groups limit the range of treatment options for physicians in an effort to keep cost down. This limitation drives a wedge in the communication between a physician and a patient. If a given care service is not covered by the managed care group, in most cases, the physician cannot offer this option to the patient. These so-called "gag rules" are detrimental to the physician-patient communication bond (Blendon et al. 1994). Some contracts forbid physicians from advocating treatments for which the HMO will not approve payment, disclosing bonuses physicians may receive as a result of denying services to their patients, or both (Bodenheimer 1996). Physicians are considered fiduciaries for patients--a person who has the power over the affairs of another party and who is required by law to act on that person's behalf (Rodwin 1995). Since gag rules prevent physicians from communicating all treatment options to patients, such rules interfere with effective discharge of a physician's fiduciary responsibility to the patient.

Satisfaction

Honesty and communication demonstrate compassion toward patients. Providers who are forced to practice with their hands tied are not able to act compassionately towards their patients. For example, Rodwin (1995) proposes that managed care plans restrict choices by:

1. Excluding medical services through management decisions that limit resources available to physicians (such as reducing budgets for equipment).

2. By imposing rules and incentives that encourage physicians to practice more frugally--thus not considering, or recommending, certain medical options.

3. By excluding certain medical services from the benefits package.

A physician who informs a patient that they have a fatal disease for which the patient needs certain treatment, but advises that the required treatment will not be approved by the organization is not likely to be viewed as having compassion. Rodwin's work indicates that lack of compassion will decrease the bond between physicians and patients. These researchers conclude that the physician-patient relationship is a positive bond that can support health status.

The managed care structure also does not encourage continuity of care and continuity has been linked to positive physician--patient relationships and positive assessments of health status. For example, Sinusas (1989) found that patients felt that it took an extended period of time for the physician to know them both emotionally and medically. In this study, patients felt the relationship became stronger over time and took multiple visits for a trusting relationship to form. Specifically, patients felt it took 2 to 5 years for the physician to get to know them medically and more than rive years for the physician to know their emotional needs. Weiss and Ramsey (1989) also demonstrated that patient satisfaction increases as continuity increases. They found that patient responses associated with more continuity reported higher levels of satisfaction with all items examined by these researchers, Items examined included: (1) patient perceptions of the carefulness of the physician routinely seen, (2) amount of concern shown, (3) willingness of the physician to listen to the patient, (4) willingness of the physician to spend enough time with the patient, and (5) adequacy of information provided by the physician.

Hjortdahl and Laerum's (1992) work on the physician-patient relationship, continuity of care, and patient satisfaction also supports this paper's call for further research on the corporate practice of medicine and health status. These researchers found that continuity was associated with patient satisfaction and the satisfaction rate was increased by seven times the satisfaction rate of patients that did not have a strong physician-patient relationship. Dissatisfaction resulted in higher rates of patient noncompliance with physician instructions and noncompliance was related to treatment outcomes. Smith and Thompson (1993) specifically looked at the frustrations voiced by patients entering a managed care system who were no longer able to see "their doctor." Their work also pointed to the positive impacts of long term physician-patient relationships for chronic conditions such as myocardial infarction and cancer.

Summary

Questions for future research related to the corporate practice of medicine and long-term health status:

1. How might executive decisions, and the associated clinical decisions invariably framed by executive policy choices, change if the only possibility of profit was demonstrated improvement in averages for specific health status indicators for an enrolled population, i.e. improved cholesterol levels, blood pressure levels, incidence of diabetes, etc.?

2. What are examples of ways that policy makers in a position to reward corporate behavior can work to improve long-term health status in the United States by shifting to health policy goals driven by attainment of measurable health status outcomes?

3. How important are physician-patient relationship characteristics like trust, quality, and patient satisfaction to improvements in measurable long-term health status indicators?

Ways to Restrict Access

As indicated previously, the term managed tare generally describes a variety of organizational structures that organize physicians, hospitals, and other providers into groups for the purpose of offering healthcare services to enrolled populations. This section of the paper will report ways that some managed care providers may influence long-term health status by restricting access to care in ways that presumably would enhance the organizational profitability. While profits are expected in competitive structures, of research concern in this work is the extent to which restriction of access may translate into impact on long-term health status. Specifically, this work is concerned about the need for more research to indicate health status parameters under which profit is appropriate. One study examined the reduced access and quality question and suggested that managed care plans are associated with reduced quality. As an example, these researchers point out that if all American women between 50 and 69 enrolled in for-profit managed care plans, an estimated 5,925 additional breast cancer deaths would be expected (Himmelstein et al. 1999). Other studies have shown that vulnerable groups (seriously ill, mentally ill, and the poor) have received worse healthcare from managed care compared to private insurance companies (Himmelstein et al. 1999). In this context, the restriction literature appears to fit well into descriptive categories of either doing less or denying care for the enrolled population.

Do Less

While the range of concerns about the corporate practice of medicine is growing, two reservations that pervade the denial literature is that providers are rewarded for providing less care and that American medicine has become a business. Too often, managed care organizations appear to focus on providing minimum treatment for acute problems, but fail to adequately treat chronic conditions which affect long-term health (Bailey 1999). A recurrent related theme was the general business strategy of substituting less expensive types of treatment for traditional ways of treating the same conditions. For example, managed care plans have been round to encourage physicians to prescript medications for treatment (which was considered less expensive treatment) instead of ordering further tests, and more costly treatments (Terry 1999).

Many inpatient physicians have been forced by managed care plans to transfer patients to facilities that have contracts with the managed care plan before the patient has attained optimal benefit. If physicians refuse to transfer the patient, financial penalties, or loss of professional position could be enforced on the provider (Loewy & Loewy 1998). Managed care plans are rewarded for reducing the number of second medical opinions (SMOs). Since SMOs do not generate revenue, providers try to maintain control over when and how SMOs are used. Six states now have laws requiring health plans to provide, or authorize, SMOs in order to preserve patient choice and improve health outcomes (AHRQ 2000). In this and similar cases, some researchers argue that managed care organizations are rewarded for encouraging patients needing expensive care to leave the plan to get the care. By comparison, plans generally have no financial incentive to provide patients with an effective way to voice their objections to denials of care (Annas 1997).

Deny More

So-called "gag rules" are common in managed care plan contracts with physicians. Gag rules may prohibit physicians from advocating treatment for their patients. Some rules prohibit physicians from disclosing to patients that bonuses are associated with denial of service to their patients (Bodenheimer 1996). Policies such as these diminish physician autonomy to make clinical decisions in the best interests of patients. This situation is also associated with a loss of patient trust that can which impact the physician-patient relationship (Levinson et al. 1999). Another denial issue is restricting hospital stays. So-called "drive-through deliveries" are one example of ways to restrict hospital stays. These are cases where mothers are discharged after only 24 hours after delivery. By 1996, 28 states had passed legislation preventing managed care plans from restricting coverage of postpartum hospital care (Bodenheimer 1996). The media, however, has been quick to point out when babies have died (supposedly) due to early discharge.

A related way to do less in the provision of care is to deny care through review. In one reported case, a young man with serious psychiatric problems was admitted to a psychiatric hospital. When the managed care organization felt he had stayed in the hospital long enough they put pressure on the doctor to discharge him. The patient was discharged and later committed suicide. The physician reviewer for the insurance company who put the pressure on the psychiatrist was a physician student in neurology. Some physicians and nurses who work for managed care plans are not qualified to make decisions about medical conditions as identified in the above example. Reviewers are also receiving bonuses for the more they deny medical care or reimbursement to patients (Ziegler 1996).

Managed care plans have also restricted access by simply denying treatment or establishing unrealistic treatment criteria a patient must meet before receiving needed care. For example, managed care plans are shifting costs for chronic conditions, including mental healthcare, to the patient. Plans may limit coverage or try to direct patients to medication instead of providing more expensive therapy (Spragins 1997). Denying payment for emergency services tops the list of concerns in this area. Retrospective denials occur when a plan enrollee seeks medical care at an emergency room prior to receiving authorization from their health plan. Unfortunately, the problem lies in the definition of an "emergency". Thirteen states have solved that problem by requiring HMO's to pay for emergency department visits if the reason for the visit would be defined as an emergency by a "prudent layperson" (Bodenheimer 1996). According to some reports, Medicaid managed care plans have a worse record than the regular Medicaid plans. For example, one Medicaid representative is reported to have opined that "A game is being played with denials. It's a financial strategy--deny or pay as slowly and unwillingly as possible because some people will give up." Plans that deny or delay authorization are using a business tactic (Aston 2000). In this regard, The American Journal of Emergency Medicine recently devoted rive research reports, a policy report, and an editorial to the issue of emergency coverage. This journal reported widespread denials of care for emergency coverage, even in states with laws designed to curb such practices (Pallarito 2000).

Summary

Questions for future research related to the corporate practice of medicine and long-term health status:

1. What are examples of medical conditions in which restricted access to care may negatively impact long-term health status?

2. What are examples of ways that corporate providers may increase profitability by focusing on practices consistent with positive assessments of long-term health status?

3. What are examples of ways that corporate providers may compete on the basis of positive assessment s of health status?

Ways to Measure Health Status

This section of the paper addresses the third research question: what are examples of methodologies and systems used to evaluate health status and outcomes? The issue of outcome accountability is likely to be debated with growing intensity as costs associated with the corporate practice of medicine continue to rise. Is it possible for policymakers and those who pay for healthcare to hold corporate providers accountable for long-term health status? This section of the paper will address this research question by highlighting ways that corporate providers of care could measure health status of enrolled populations for which they are accountable.

The literature reflects that the criteria for evaluating the outputs of corporate managed care organizations have shifted from price to performance in recent years (Marwick 1997). The emerging emphasis on quality and the assessment models identified in this work, have increased as the corporate practice of medicine has further penetrated the healthcare marketplace (Brook 1997). While, physician gatekeeper roles and managed care plan rules built a perception of inappropriately rationing care, Brook's (1997) research with the RAND Corporation argues that managed care, by itself, is not the problem with healthcare. Quality is the issue. Similarly, RAND researchers have noted that poor quality can mean too much, too little or the wrong care (RAND Health 1999). The Agency for Health Care Policy and Research (AHCPR) (1998b) emphasizes the need to focus on quality definitions citing under-use, over-use, misuse and practice variations as quality issues.

Healthcare research has consistently shown that losing or acquiring health insurance affects individual health status (Brook et al. 1996). Mortality rates can be up to 25 percent higher for the uninsured (Chassin, Galvin & National Roundtable on Health Care Quality 1998). While financial overhauls of the healthcare system have addressed some access issues, financial restructuring may not have summarily resulted in improved health status of the population. In this regard, quality problems and large variations in practice patterns have plagued the system for years. Multiple case review methods and algorithms have been employed to identify practice variations that lead to poor individual outcomes and address them on a case by case basis. Some researchers in this area suggest the need to focus instead on outcome management for groups (Nerenz 1997).

This paper advocates further research to identify global measures appropriate for assessing the extent to which factors like the corporate practice of medicine may impact system outcomes like long-term health status. The schools of thought on what should be measured, how its should be measured and who should have access to the measurements has fueled much research and debate. Increased access to detailed clinical information through automated data repositories have expanded the horizons of those seeking to develop valid methodologies (Shaller, Sharpe & Rubin 1998). The Health Care Financing Administration (HCFA), as the largest single purchaser of healthcare, raised the bar by formulating new policies and mandating complex quality/outcomes assessment mechanisms (Voelker 1997; HCFA 1997; HCFA 1998). The literature supports several different organizing frameworks for discussion of health status and assessments. The classic structure, process and outcome divisions seem generally favored in writings on quality. This endeavor is better served by looking at methodologies based on type and source of data collected in the care evaluation process. This approach allows exploration of concerns on comprehensiveness, validity and cost of data collection.

Administrative Data Measures

Mortality rates, morbidity rates and lire expectancy were once the gold standard of health outcomes measurement (Cheater 1998). They represent a form of analysis achieved by actuaries working with public health data and are not particularly sensitive to subtle changes in care delivery or financing. The impact of changes is often a delayed finding and there are many confounding variables. These assessments had their time when mortality and morbidity from communicable disease were high and life expectancy was low, and they are used to address system effectiveness when comparing across nations (Williams & Torrens 1999).

Report cards models are emerging as one major assessment methodology. For example, The Department of Defense's TRICARE Operational Performance Statement (1999) is a report card type product that also includes data on incidence of preventable diseases as one of its population health outcome measures. This methodology is limited to administrative data extracts and delivers reports at the population level only. However, the most widely used report card in managed care organizations is the National Committee on Quality Assurance's (NCQA's) Health Plan Employer Data Information Set (HEDIS). This performance measurement tool includes population health status measures and is used by more than 90 percent of the managed care plans in the United States (NCQA 1999). It too relies on administrative data from plan files and claims data to generate assessments. Originally designed as a voluntary measure with optional public release of findings, the impact of HEDIS has exploded. HCFA (1998) mandated the use of HEDIS for healthcare plans receiving funds under Medicare and Medicaid and will release the reports (Gallagher, Alpers & Lo 1998). HCFA (1998) is planning to evaluate data completeness in addition to plan performance. The current version of HEDIS contains 14 clinical quality measures that track treatment processes for acute and chronic diseases, prevention and screening (Epstein 1998). HEDIS[R] 2000 introduces rive new clinical measures aimed at processes known to impact health outcomes for conditions present in nearly 70 million Americans (NCQA 1999). Process measures are supported because patients may get better despite intervention and/or not develop adverse outcomes in a short period of time (Brook, McGlynn & Cleary 1996).

HEDIS has a number of drawbacks. One is high data collection costs because only NCQA certified vendors perform the required data extractions. While, emphasis on counting interventions may address some problems with under utilization, it also increases short-term health plan costs (Mainous & Talbert 1998). Medicaid providers may not be required to submit claims to receive capitation and therefore completeness can surfer. The system also has no mechanism for risk adjusting populations so its validity as a report card to compare outcomes between plans is impaired (Mainous & Talbert 1998; Bodenheimer 1999).

The Nationwide Inpatient Sample (NIS) is another administrative data set used to evaluate care outcomes (AHCPR 1999). This enterprise database contains records from more than 6 million inpatient stays between 1988 and 1996 in 900 hospitals covering 14 states. As an all-payer system, it allows global benchmarking and analysis of outcomes of high-tech hospital procedures. NIS is an actuary's dream and is currently utilized by the insurance industry and policy makers at the macro level. Its limits include the inpatient focus that prevents assessment of outcomes across the continuum of care and reliance upon claims data. Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs) are also generated from inpatient administrative data sets. This add-on system has prepackaged studies designed to address under and over utilization and preventable admissions. HCUP QIs focus on outcomes like preventable mortality and complication rates. The limitations mirror those of NIS.

Patient Self-Report Measures

Brook et al. (1996) suggests that patients must be active participants in the evaluation of the healthcare system, the effectiveness of care, and functional outcomes. Further, Brook, McGlynn & Cleary (1996) suggest that multi-factorial methodologies be employed that include administrative, clinical (disease specific) and patient self-report data in order to accurately capture health status and outcomes. They note that if outcome data are to be used to aid individuals in health plan selection, patient satisfaction is a vital measure of quality as well. RAND (1999) is currently marketing its newly validated products and feels that it has the tools necessary. Over the past decade, RAND has developed more that 1,000 criteria that form a comprehensive set of measures of the quality of care delivered to men, women, and children. RAND developed mechanisms to obtain this information from both patient surveys and medical records and also developed measures of health status and patient satisfaction that can be used to assess the effects of changes in healthcare policy.

Policies developed to implement portions of the Balanced Budget Act of 1997 (BBA 1997) mandated the multi-factorial approach for Medicare+Choice HMOs and Section 1876 risk plans (HCFA 1997). The tools required in policy are combined into a program called the Quality Improvement System for Managed Care (QISMC). QISMC includes two patient self-report instruments in addition to the most current version of HEDIS. The Consumer Assessment of Health Plans Study (CAHPS) is the patient satisfaction instrument in QISMC. Developed by a consortium of Harvard University, RAND, the Research Triangle Institute and AHCPR, QISMC aims to serve the needs of institutional health plan purchasers and individual consumers (RAND 1996). It evaluates access parameters and consumer perceptions of the acceptability of care. CAHPS was planned for initial use in 1999 by the US Office of Personnel Management to report consumer assessments of health plans for Federal Employee Health Benefit Program participants (AHCPR 1998b). State Medicaid agencies are also using CAHPS. Epstein (1998) notes that 80 percent of these agencies have plans to mandate CAHPS or other tested access measures. He discusses the prevailing wisdom on use of patient feedback to measure access is that it is more likely to capture the data than administrative means or record review.

The second patient self-report component of QISMC is the Health Outcomes Survey (HOS) and is designed to longitudinally measure a health plan's ability to improve health status of individual enrollees (NCQA 1998a, 1998b). Originally called the Health of Seniors Survey, this tool was developed from the well-validated SF-36 health measurement tool (Ware et al. 1994; NCQA 1998a; Nerenz 1997). It includes additional questions designed to allow for risk-adjustment and others necessary to meet the mandate of the BBA 1997. HOS requires the plan to contract with an approved vendor to assess health status of up to 1,000 beneficiaries (NCQA 1998b). The selected individuals complete the survey via phone or mail in at an initial point, and then two years later. HOS purports to measure physical and mental health functions of Medicare beneficiaries and be able to identify changes in health status.

Jones et al. (1997) describe the SF-36, and the more abbreviated tool, SF-12 that were initially developed by the Medical Outcomes Trust (Ware et al. 1994, 1998). SF-12 and SF-36 measure one's functional status and well being. Brook et al. (1996) favor functional status assessment on a selected sample of plan enrollees. These authors suggest using results to develop service lines that address identified preventable or correctable functional impairments. The SF-36 and SF-12 have been validated and refined on multiple populations and work well for a variety of age groups (Jones et al. 1997; NCQA 1998a). These simple tools are frequently used for health status research and commercial applications.

Kaiser Permanente has tested a health status instrument for geriatric patients. In an effort to creatively manage its over-age-65 members, the Health Status Form (HSF) was used to predict frailty and increased need for resources (Brody et al. 1997). The HSF instrument is mailed directly to plan members and returned by mail. Reminder cards and additional instrument mailings generated a return rate of nearly 90 percent. HSF has proven to be a powerful predictive tool for initial screening and in longitudinally assessing changes in health status. Scores define sub-populations/individuals in need of case management or other services aimed at mitigating effects of chronic disease. Population level data allows health system interventions to meet the needs of members.

Another variation on health status assessment tools include the plethora of Health Related Quality of Life (HRQRL) instruments. Cheater (1998) strongly supports the need for these evaluation methodologies noting that survival rates and other practitioner-determined interpretations of health status rail to take into account the psychological and social impact of care. According to this author, HRQRL tools attempt to capture the dimensions of health outcomes that have an impact on patients' lives. To do so, they must be disease specific and a recent text identifies more than 225 instruments (Cheater 1998). Cleary and Levitan (1997) report that research driven HRQRL measures have proven valid and reliable, and responsive to important clinical changes. Noteworthy for this assessment area is that Epstein (1997) highlights difficulties in adequately and accurately surveying low-income populations.

Disease Specific and Multi-source Measures

The Foundation for Accountability (FACCT) is a consumer oriented, not-for-profit organization that has built an information framework to simplify sharing health status improvement performance measures (Skolnick 1997; Epstein 1998). FACCT developed indicators for a number of specific diseases and conditions such as diabetes, asthma, and major depression. These indicators are now being evaluated by RAND under a HCFA grant. RAND's work has been endorsed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Jones et al. 1997). According to Skolnick (1997), FACCT's evaluations are based on provider measures in rive question categories:

1. Are providers delivering the basics of good care? 2. Do providers help patients stay healthy? 3. Do providers help patients get better when they have an acute illness? 4. Are providers able to help patients with chronic illnesses maximize quality of life? 5. Do providers help patients and families adjust to changing health status?

FACCT, in conjunction with the American Diabetes Association (ADA), NCQA and HCFA has developed a robust disease specific health status/outcomes measure called the Diabetes Quality Improvement Project (DQIP). The tool was designed to evaluate complex care processes (NCQA 1998b). "The charge to the DQIP expert committee was to evaluate and recommend a set of diabetes specific performance and outcome measures with which health plans, physicians, clinics and other healthcare providers could be compared for the purposes of accountability" (ADA 1998). This comprehensive measure has been adopted by the NCQA for use in HEDIS. DQIP currently includes sets of accountability measures and quality improvement measures. Field testing of patient measures that address self-management education, provider interpersonal relationships and satisfaction will add a third domain to the DQIP evaluation methodology. HCFA is using DQIP as a model clinical outcome measure for the Medicare+Choice plans.

Disease specific measures have been adopted in several states as part of health consumer education and awareness efforts. Coronary Artery Bypass Graft (CABG) report cards are used in New York and Pennsylvania (Epstein 1998). The New York CABG initiative publishes hospital and provider specific mortality data. Since its inception, mortality rates have decreased dramatically. While welcomed by the states and regulators, there is debate on the suggested cause and effect of the CABG program. Epstein notes that mortality rates have dropped nationwide and both referring providers and patients have indicated that they don't use the available data.

AHCPR (1998a) has delved further into outcomes and clinical performance measures with the development of a COmputerized Needs-oriented QUality Measurement Evaluation SysTem (CONQUEST). CONQEST uses interlocking databases that combine clinical service codes and health outcomes related to certain measures and conditions. This software tool is an off-the-shelf, public-use database available to users free of charge. CONQUEST provides instant access to nearly 1,200 measures, identifies data extraction requirements and specifications. Identified potential CONQUEST user groups run the gamut from individual healthcare providers to government policy makers. CONQUEST includes 53 measurement sets validated by research studies initiated by RAND, JCAHO, Maryland Hospital Association and others. Expansion of Quality of Care Measures (Q-SPAN) is another product derived from AHCPR's efforts (1998a) and is a follow-on to the CONQUEST effort. Q-SPAN incorporates eight projects that are currently evaluating additional assessment measures in the areas of dental care, asthma, managed care, cardiovascular disease, functional outcomes of hip fracture patients, benchmarks, HEDIS, and subacute/home care. Validated, the measures will be added to CONQUEST. all of these measures require application of sophisticated information technology and the skills of data analysts for their effective implementation.

National Initiatives

The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry proposed creation of the Forum for Health Care Quality Measurement and Reporting (AHCPR 1998b). The purpose of the Forum is to catalyze a national effort that will ultimately result in a uniform framework for measuring quality. The Forum has been charged with rive complex tasks. They are expected to identify core sets of measures for standardized reporting, and establish the framework and capacity to use these measures. The need for such a national effort has been readily recognized. Epstein (1998) cites incomplete measures, lack of standardization, problems with risk adjustment, operational limitations and lack of knowledge as significant impediments to being able to produce valid report card systems. Certain measures have proven more difficult to develop. Gallagher (1998) identifies substantial problems with current measures designed to detect under utilization. He proposes development of new measures that are particularly sensitive to those care decisions most likely to be affected by financial incentives. RAND Health (1999) adds urgency to the effort and suggests doing whatever is necessary to develop an overarching strategy.

Summary

Questions for future research related to the corporate practice of medicine and long-term health status:

1. What are examples of ways in which health status measures currently employed by corporate providers distort an accurate assessment of enrollee long-term health status?

2. What are examples of ways to increase corporate provider accountability for positive assessments of long-term health status for enrolled populations?

3. What factors preclude holding corporate providers accountable for positive assessments of long-term health status for enrolled populations?

CONCLUSION

The purpose of this paper was to identify possible areas for future research related to the corporate practice of medicine and its possible impact on long-term health status. The paper introduced the central notion that the corporate practice of medicine in the United States and its relationship to long-term health status should be a national healthcare policy issue. The literature examined in this paper indicates that further research is needed to ascertain critical relationships among the physician-patient relationship, ways to hold corporate providers of care accountable for assessments of health status, and appropriate long-term health status measures. This conclusion suggests the need for a paradigmatic shift in the way health system stakeholders view their social obligations relative to the communities they purport to serve. In the final analysis, the central question that must be addressed by both public and private leadership is the extent to which Wall Street and the corporate practice of medicine shall be allowed to profit from short-term gains that may be inconsistent with long-term health status in the US.

(1) Mg. Ed. Note: Some would further argue that "managed care" itself is a misnomer, and that capitated payment systems in general should be more appropriately termed short-term "managed cost" systems. The reason being that with employer-based health coverage, the mobility of the US working population causes providers who invest in preventative care (managed care) to lose the long-term benefits to subsequent-employer-based health plans. Alternatively, providers who limit access, under-treat or defer care can realize the short-term cost savings (managed cost), while subsequent-employer based health plans incur the higher long-term cost of treatment for the patient. This can be addressed by portable or national-scope health plans that follow the employee, and thus enable providers to realize the long-term cost-saving benefits of investing in preventative care for the covered employee.

One of the primary misconceptions in this regard is that escalating healthcare costs are allegedly due to unnecessary patient self-referrals to specialists, and thus "managed care" gatekeeping (i.e. limiting access) is necessary to curb the explosion in costs. On the contrary, the culprit in escalating costs is the 25-year US history of federally-sponsored cost-based reimbursement policies that provided significant financial incentives to build over-capacity and maximize healthcare costs. The cure is hot incentivising under-treatment, or incentivising over-treatment, the cure is incentivising appropriate care, which is the highest quality of care for the patient in the long term.

REFERENCES

Annas, G. (1997) "Patients' Rights in Managed Care--Exit, Voice and Choice," The New England Journal of Medicine, 337(2):210-215.

Angell, M. & J.P Kassirer (1996) "Quality and the Medical Marketplace--Following Elephants," The New England Journal of Medicine, 335(12):883-885.

Aston, G. (2000) "Managed Care Plans Shirk Emergency Care Payments," American Medical News, (March 13):32-35.

Agency for Healthcare Research and Quality (2000) Access to Second Medical Opinions is Determined in Part by Sociocultural Factors and Type of Insurance: Overview, Agency for Healthcare Research and Quality, 233.

Agency for Health Care Policy and Research (1998a) Consumer Assessment of Health Plans (CAHPS[TM]): Overview, Agency for Health Care Policy and Research.

Agency for Health Care Policy and Research (1998b) The Challenge and Potential for Assuring Quality Health Care for the 21st Century, Agency for Health Care Policy and Research, www.ahcpr.gov/qual/21stcena.htm.

Agency for Health Care Policy and Research (1999) HCUP Quality Indicators: Summary, Agency for Health Care Policy and Research, www.ahcpr.gov/data/hcup/hcupqi.htm.

American Diabetes Association (1998) Diabetes Quality Improvement Project Initial Measure Set (Final Version), American Diabetes Association.

Bailey, R. (1999) "Care of Chronically Mentally III Patients in a Managed Care Environment," American Journal of Psychiatry, 156(11): 1801-1807.

Blendon, R.J., R.A. Knox, M. Brodie, J.M. Bensen & G. Chervinsky (1994) "Americans Compare Managed Care, Medicine, and Fee for Service," Journal of American Health Policy, 4:42-47.

Bodenheimer, T. (1996) "The HMO Backlash-Righteous or Reactionary?" The New England Journal of Medicine, 335 (21):1601-1603.

Bodenheimer, T. (1999) "The American Health Care System--The Movement for Improved Quality in Health Care," The New England Journal of Medicine, 340(6):488-492.

Brody, K., R. Johnson & L. Ried (1997) "Evaluation of a Self-report Screening Instrument to Predict Frailty Outcomes in Aging Populations," The Gerontologist, 37(2):182-191.

Brook, R., C. Kamberg & E. McGlynn (1996) "Health System Reform and Quality," The Journal of the American Medical Association, 276(6):476-480.

Brook, R., E. McGlynn & P. Cleary (1996) "Part 2: Measuring Quality of Care," The New England Journal of Medicine, 335(13):966-970.

Brook, R. (1997) "Managed Care Is Not the Problem, Quality Is," The Journal of the American Medical Association, 278 (19): 1612-1614.

Chassin, M., R. Galvin & National Roundtable on Health Care Quality (1998) "The Urgent Need to Improve Health Care Quality: Institute of Medicine National Roundtable on Health Care Quality," Journal of the American Medical Association, 280(11): 1000-1005.

Cheater, F. (1998) "Quality of Life Measures for the Healthcare Environment," Nurse Researcher, 5(3): 17-30.

Cleary, P. & S. Edgman-Levitan (1997) "Health Care Quality: Incorporating Consumer Perspectives," The Journal of the American Medical Association, 278 (19): 1608-1612.

Emanuel, E.J. & N.N. Dubler (1995) The Journal of the American Medical Association, 273(4):323-329.

Epstein, A. (1997) "Medicaid Managed Care and High Quality: Can We Have Both?" The Journal of the American Medical Association, 278(19):1617-1621.

Epstein, A. (1998) "Rolling Down the Runway: The Challenges Ahead for Quality Report Cards," The Journal of the American Medical Association, 279(21):1691-1696.

Fowles, J.B., J.P Weiner, D. Knudson, E. Fowler, A.M. Tucker & M. Ireland (1996) "Taking Health Status into Account when Setting Capitation Rates," The Journal of the American Medical Association, 276(16):1316-1321.

Gallagher, T., A. Alpers & and B. Lo (1998) "Health Care Financing Administration's New Regulations for Financial Incentives in Medicaid and Medicare Managed Care: One Step Forward?" American Journal of Medicine 105(5):409-415.

Grumbach, K. (1999) "Primary Care in the United States--The Best of Times, the Worst of Times," The New England Journal of Medicine, 341(21):2008-2011.

Health Care Financing Administration (1997) Operational Policy Letter #59, www.hcfa.gov/medicare/op1059.htm.

Health Care Financing Administration (1998) Addendum II to OPL #59, www.hcfa.gov/medicare/op1059b.htm.

Himmelstein, D.U., S. Woolhandler, I. Hellander & S. Wolfe (1999) "Quality of Care in Investor-owned vs. Not-for-Profit HMOs," The Journal of the American Medical Association, 282(2):159-163.

Hjortdahl, P. & E. Laerum (1992) "Continuity of Care in General Practice: Effect on Patient Satisfaction," British Medical Journal, 304:1287-1290.

Inglehart, J.K. (1995) "Health Policy Report: Medicaid and Managed Care," The New England Journal of Medicine, 332(25):1727-1731.

Jones, K., B. Jennings, P. Moritz & M. Taylor (1997) "Policy Issues Associated with Analyzing Outcomes of Care," Image Journal of Nursing Scholarship, 29(3):261-267.

Kaplan, S., S. Greenfield & J. Ware (1989) "Assessing the Effects of Physician-patient Interactions on the Outcomes of Chronic Disease," Medical Care, 27(23):S110-S127.

Kassirer, J.P. (1995) "Managed Care and the Morality of the Marketplace," The New England Journal of Medicine, 333(1):50-52.

Kerr, E.A., B.S. Mittman, R.D. Hays, B. Leake & R.H. Brook (1996) "Quality Assurance in Capitated Physician Groups: Where is the Emphasis?" The Journal of the American Medical Association, 276(15): 1236-1239.

Levinson, W., R. Gorawara-Bhat, R. Dueck, B. Egener, A. Kao, C. Kerr, B. Lo, D. Perry, K. Pollitz, S. Reifstecks, T. Stein, J. Sants & M. Kemp-White (1999) "Resolving Disagreements in the Physician-patient Relationship," The Journal of the American Medical Association, 282:1477-1482.

Loewy, E. & R. Loewy (1998) "Ethics and Managed Care," Archives of Internal Medicine, 158(22):1819-1826.

Mainous, A. & J. Talbert (1998) "Assessing Quality of Care via HEDIS 3.0: Is there a Better Way?" Archives of Family Medicine, 7(5):410-413.

Marwick, C. (1997) "NCQA: Quality through Evaluation," The Journal of the American Medical Association, 278(19):1555-1556.

National Committee on Quality Assurance (1998a) HEDIS 3.0/1998 Volume 6, Health of Seniors Survey Manual, Washington, DC: National Committee on Quality Assurance.

National Committee on Quality Assurance (1998b) Letter to Medicare Health Plans, www.ncqa.org/pages/policy/hedis/health%20of%20seniors/planletter.htm.

National Committee on Quality Assurance (1999) NCQA Releases HEDIS[R] 2000 Draft: New Performance Measures Will Turn Spotlight on Care for the Chronically Ill, www.ncqa.org/pages/communicaitons/news/h2krel.html.

Nerenz, D. (1997) "Measuring Plans and Measuring Health," Annals of Internal Medicine, 127(8S):751.

RAND (1996) Health Program, www.rand.org/publications/AR/1996AR/research/health.html.

RAND Health (1999) Taking the Pulse of Health Care in America, www.rand.org/publications/RB/RB4524.

Robinson, J.C. & L.P. Casalino (1995) "The Growth of Medical Groups Paid through Capitation in California," The New England Journal of Medicine, 333:1684-1687.

Rodwin, M. (1995) "Conflicts in Managed Care," The New England Journal of Medicine, 332(9):604-607.

Sinusas, K. (1989) "Patients' Attitudes Toward the Closing of a Medical Practice," The Journal of Family Practice, 28(5):561-564.

Schuyler, N. (1997) "Managing Managed Care," In These Times, (November 2):25-27.

Shaller, D., R. Sharpe & R. Rubin (1998) "A National Action Plan to Meet Health Care Quality Information Needs in the Age of Managed Care," The Journal of the American Medical Association, 279 (16): 1254-1258.

Skolnick, A. (1997) "A FACCT-filled Agenda for Public Information," The Journal of the American Medical Association, 278(19):1558.

Smith, T.C. & T.L. Thompson (1993) "The Inherent, Powerful Therapeutic Value of a Good Physician-patient Relationship," Psychosomatics, 34(2):166-170.

Spragins, E. (1997) "Shortchanging the Psyche: Will Your HMO Be There if You Need Therapy?" Newsweek, 130(8):78-79.

Terry, K. (1999) "Hang On--The Ride's Going to Get Rougher," Medical Economics, 76(7):176-179.

TRICARE (1999) TRICARE Operational Performance Statement (TOPS), June Feature, www.tricare.osd.mil/reptcard/tops/topsrrept.html.

Ware, Jr., J.E., M. Kosinski & S.D. Keller (1994) SF-36: Physical and Mental Health Summary Scales: A User's Manual,. Boston, MA: Health Assessment Lab.

Ware, Jr., J.E., M. Kosinski & S.D. Keller (1998) SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales, 3rd Ed., Lincoln, RI: QualityMetric Inc..

Weiss, G.L. & C.A. Ramsey (1989) "Regular Source of Primary Medical Care and Patient Satisfaction," Quality Review Bulletin, 15(6):180-184.

Woolhandler, S. & D.L. Himmelstein (1995) "Extreme Risk--The New Corporate Proposition for Physicians," The New England Journal of Medicine, 333(25):1706-1707.

Woolhandler, S. & D.L. Himmelstein (1997) "Costs of Care and Administration at For-profit and Other Hospitals in the United States," The New England Journal of Medicine, 336(11):769-774. Ziegler, J. (1996) "Turning Up the Heat on Managed Care," Business and Health, 33-37.

Address for correspondence: Jimmy D. Sanders, Troy State University, 10850 US Hwy. 331, Montgomery, AL 36105 USA, [e-mail].

Jimmy D. Sanders
Troy State University (USA)