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Resolving Disagreements in the Patient-Physician Relationship
Tools for Improving Communication in Managed Care
Wendy Levinson, MD;
Rita Gorawara-Bhat, PhD;
Rodney Dueck, MD;
Barry Egener, MD;
Audiey Kao, MD;
Clark Kerr;
Bernard Lo, MD;
David Perry, MD;
Karen Pollitz, MPP;
Sandra Reifsteck, MS;
Terri Stein, MD;
John Santa, MD;
Maysel Kemp-White, PhD
JAMA. 1999;282:1477-1483.
Managed care uses financial incentives and restrictions on tests and procedures to attempt to influence physician decision making and limit costs. Increasingly, the public is questioning whether physicians are truly making decisions based on the patient's best interest or are unduly influenced by economic incentives. These circumstances lead to the potential for disagreements 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 experts, and medical ethicists, to articulate the types of disagreements emerging in the patient-physician relationship as a result of managed care. We addressed 3 specific scenarios physicians may encounter, including allocation, illustrated by a patient who is referred to a different ophthalmologist based 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 than a nurse specialist; and financial incentives, illustrated by a patient who expects to have a test performed and a physician who does not believe the test is necessary but is afraid the patient will think the physician is not ordering the test because of financial incentives. Using these scenarios, we suggest communication strategies that physicians can use to decrease the potential for disagreements. In addition, we propose strategies that health plans or physician groups can use to alleviate or resolve these disagreements.
Author Affiliations: Section of General Internal Medicine and Program for Physician Patient Communication Research, University of Chicago, Chicago, Ill (Drs Levinson and Gorawara-Bhat); Park Nicollet Clinic/Health Systems Minnesota, St Louis Park, Minn (Dr Dueck); Northwest Center for Physician-Patient Communication, Portland, Ore (Dr Egener); American Medical Association, Chicago (Dr Kao); 21st Century Consumer, Alamo, Calif (Mr Kerr); University of California San Francisco Program in Medical Ethics, San Francisco (Dr Lo); HealthFirst, Portland (Drs Perry and Santa); Institute for Health Care Research and Policy, Georgetown University, Washington, DC (Ms Pollitz); Carle Clinic Association, Champaign, Ill (Ms Reifsteck); Kaiser Permanente Medical Group, Oakland, Calif (Dr Stein); and Bayer Institute for Health Care Communication, West Haven, Conn (Dr Kemp-White).
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