Views of Managed Care — A Survey of Students, Residents, Faculty, and Deans at Medical Schools in the United States

Study Sample and Data Collection

We used the master files of the American Medical Association and the Association of American Medical Colleges to draw stratified probability samples of first-year and fourth-year medical students, residents in their third postgraduate year (excluding graduates of foreign medical schools), full-time clinical faculty members from all specialties, directors of residency training in internal medicine and pediatrics, department chairs, and medical school deans. We oversampled specific target groups (e.g., primary care faculty members) in order to ensure their adequate representation in the sample. Between March and August 1997, the Center for Survey Research of the University of Massachusetts, Boston, conducted confidential 20-minute telephone interviews with 2162 participants. The study was approved by the Human Studies Committee of Harvard Pilgrim Health Care.

Table 1. Table 1. Population Size, Sample Size, and Response Rate According to Academic Group.

For each academic group, the size of the population from which the sample was drawn, the size of the sample, and number of respondents are shown in Table 1. Response rates varied from 76.7 to 88.6 percent among subgroups; the overall rate was 80.1 percent. We defined primary care respondents as those who practiced or intended to practice in the area of family medicine, general internal medicine, general pediatrics, or geriatrics. We defined specialists as those who practiced or intended to practice any other specialty or subspecialty, or whose practice involved a combination of primary care and a specialty or subspecialty.

Development of the Survey

The questionnaires (available elsewhere, NAPS) were developed on the basis of a systematic review of the literature and the observations of focus groups of students, residents, faculty members, deans, department chairs, and directors of residency training in areas of the United States with high, intermediate, and low levels of market penetration by managed care. Participants in the focus groups were broadly divergent in their understanding of the term “managed care,” both within and among geographic regions. Because of the difficulty of arriving at a common definition, and because of the heterogeneity of managed-care organizations and programs in different areas, we allowed respondents to use their own experience and definitions of managed care in answering our questions.

Appendix.

We carried out two pilot studies with a total of 86 participants from each of the study populations and modified the questionnaires on the basis of the results. The final questionnaires included items designed to measure elements of academic culture in relation to managed care (outlined in the Appendix). To minimize the length of the questionnaires and the time necessary to complete the survey, we excluded questions to which the responses varied little during preliminary testing. A majority of the respondents in the pilot studies considered managed care better than fee-for-service care in terms of preventive services, the coordination of care, cost effectiveness, and avoidance of unnecessary care. Similarly, a majority of respondents in the pilot surveys found fee-for-service care superior to managed care in terms of access to surgical care, tests, procedures, and “high-technology” experimental therapies.

Statistical Analysis

Because we oversampled several subgroups of respondents and sampled a different fraction of the total population of each academic group, we used sampling weights to adjust for differences in the probability of selection in all analyses. All estimated means and percentages are weighted statistics and therefore represent estimates of the responses of the national populations of students, residents, faculty members, medical school deans, department chairs, and directors of residency training in internal medicine and pediatrics within U.S. academic health centers. To estimate the responses and their standard errors appropriately,^15,16 we used a specialized statistical program, SUDAAN,¹⁷ which is designed for the analysis of complex probability-sample data.

For binary, nominal, and ordinal outcomes, we constructed a series of logistic-regression, multinomial logistic-regression, and ordinal logistic-regression models, respectively, to assess whether variation in the responses was associated with the academic group or a specialty orientation (the main effect), and whether the effect of specialty orientation differed among academic groups (an interaction effect).^18,19 In cases in which the assumptions for ordinal logistic regression were violated, we refitted the models using the more generalized, nonordered, multinomial logit model.²⁰ For continuous outcomes, we fitted linear regression models to test for variation among academic groups or according to specialty orientation.²¹ Three groups were not included in analyses according to specialty orientation: deans, because the number of deans in primary care was too small for analysis; directors of residency training, because there were no specialists in this group; and students and residents (51 and 14, respectively) who were undecided about their career plans and therefore could not be categorized according to specialty orientation.

We also examined whether variations in the perceived effects of managed care on the academic mission and professional life of the faculty were related to the respondents' level of exposure to managed care, as measured by physicians' reports of the proportion of their patients who were enrolled in managed care and by the competitiveness of the managed-care market in each respondent's geographic area.^10,22 The index of competitiveness we used was that of the University HealthSystem Consortium, which classified the competitiveness of U.S. health care markets on the basis of the number of health maintenance organizations (HMOs) with more than 100,000 enrollees, the percentage of all enrollees in the three largest HMOs, hospital occupancy rates, the average number of hospital days per 1000 population, the percentage of specialists who were paid on a capitated basis, the percentage of Medicare and Medicaid beneficiaries enrolled in HMOs, and the average premium for a commercial HMO in 1995.^10,22

To test for differences among items assessed for individual subjects, we used repeated-measures analysis of variance. We used adjusted Wald F statistics to test hypotheses, because of the stratification and unequal sampling fractions.¹⁷ All reported P values are two-tailed. To adjust for the increased risk of a type I error resulting from the multiple tests of hypotheses, we used P<0.01 as the criterion for statistical significance.

Attitudes toward Managed Care

In general, students, residents, faculty members, directors of residency training, department chairs, and deans reported negative attitudes toward managed care. On a 0-to-10 scale (with 0 indicating an attitude as negative as possible and 10 an attitude as positive as possible), mean (±SD) scores for the respondents' attitudes toward managed care ranged from a low of 3.9±1.7 for residents to a high of 5.0±1.3 for deans. Primary care respondents reported less negative feelings about managed care than specialists (mean score, 4.6 vs. 4.0; P<0.001).

Table 2. Table 2. Ratings of Fee-for-Service and Managed-Care Systems, According to Academic Group and Aspect of Care.

Table 2 shows respondents' comparisons of managed-care with fee-for-service delivery systems with regard to access to physicians, the presence of ethical conflicts, the quality of the doctor–patient relationship, continuity of care, the quality of end-of-life care, and the management of chronic illness. In terms of all these features, a higher proportion of respondents rated fee-for-service systems superior to managed care. The highest ratings for managed care were for management of chronic illness and continuity of care, with 30.8 percent and 29.3 percent of respondents, respectively, identifying managed care as the better system. In general, specialists were more likely than primary care respondents to prefer fee-for-service medicine to managed care on most measured dimensions of clinical care. Responses also varied according to academic group, with faculty members and department chairs expressing the greatest preference for fee-for-service medicine over managed care. There was an interaction effect in several of the models, indicating that department chairs who were specialists were the most likely of the subgroups to favor fee-for-service medicine over managed care.

All groups expressed a preference for a single-payer health care system over both managed-care and fee-for-service systems. Overall, 57.1 percent thought that a single-payer system with universal coverage was the best health care system for the most people for a fixed amount of money. A total of 21.7 percent favored managed care, and 18.7 percent preferred a fee-for-service system (2.5 percent did not state a preference).

Effects of Managed Care on Academic Medicine

Table 3. Table 3. Reported Effects of Managed Care on Academic Medicine, According to Academic Group.

A total of 63.1 percent of faculty members, directors of residency training, and department chairs and 96.2 percent of deans thought that managed care had decreased faculty members' time for research (either a lot or a little) (Table 3). Similarly, 58.9 percent of faculty members, directors of residency training, and department chairs and 93.4 percent of deans reported that teaching time had been reduced by managed care. A total of 26.9 percent of faculty members, directors of residency training, and department chairs and 52.6 percent of deans believed that managed care was decreasing care for traditionally underserved groups of patients. As compared with faculty members in primary care, specialists were nearly twice as likely to report “a lot” of (as compared with little or no) reduction in research time because of managed care (34.4 percent vs. 20.9 percent; odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.9).

Effects of Managed Care on the Quality of Professional Life

More than half of faculty members, directors of residency training, and department chairs reported that their income had decreased a lot or a little (reported by 55.8 percent of these respondents), that job security had diminished (54.1 percent), and that collegial relations had deteriorated (52.2 percent) as a result of managed care (Table 3). Similarly, 79.1 percent of deans reported a decrease in faculty members' income; 81.9 percent reported a decline in job security for faculty members; and 61.9 percent reported poorer collegial relations among the faculty. Specialists were more likely than those in primary care to report “a lot” of (as compared with little or no) decline in income (19.3 percent vs. 6.5 percent; odds ratio, 2.8; 95 percent confidence interval, 1.6 to 4.6). Results also varied according to academic group, with directors of residency training less likely to note an effect of managed care than faculty members and department chairs (odds ratio, 0.28; 95 percent confidence interval, 0.14 to 0.59).

Exposure to Managed Care and Perceptions of Its Effects

Faculty members, directors of residency training, and department chairs who cared for higher proportions of patients enrolled in managed-care plans were more likely to report that they had decreased time available for research and a diminished level of job security (data not shown). For example, our models estimated that faculty members who reported that 75 percent of their patients were enrolled in managed-care plans were 1.6 times as likely to report that their job security had decreased “a lot” (rather than “a little” or “not at all”) as a result of managed care than were faculty members who reported that 25 percent of their patients were enrolled in managed-care plans.

Deans' Views of Managed Care

More than two thirds of deans (72.5 percent) reported that there had been a decline in their schools' overall budgets for medical education as a result of managed care; 85.9 percent of deans perceived resistance from managed-care organizations to collaboration with medical schools in medical education, with 62.8 percent reporting “a lot” of resistance. The level of competitiveness of the local managed-care market was unrelated to deans' reports of the effects of managed care (data not shown).

The Message about Managed Care

Overall, 46.6 percent of all faculty members, 26.7 percent of directors of residency training in internal medicine and pediatrics, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. In contrast, only 16.2 percent of deans said that their schools conveyed a negative message about managed care. Primary care respondents were more likely than specialists to report that they conveyed a positive message about managed care (26.0 percent vs. 10.6 percent, P<0.001).

Influences on Students' and Residents' Attitudes toward Managed Care

Table 4. Table 4. Students' and Residents' Report of Influences on Their Attitudes toward Managed Care.

Table 4 shows students' and residents' perceptions of the influences on their attitudes toward managed care. Overall, the three most frequently reported influences were coursework or the medical literature (64.8 percent), primary care faculty members (60.8 percent), and specialist faculty members (58.7 percent). Among students and residents reporting those influences, more than 70 percent described the influences as negative. Overall, 55.8 percent of students and residents identified no positive influences on their attitudes toward managed care.

Exposure to Managed Care

Fourth-year medical students estimated that they spent a mean of 4.2±6.6 percent of their clerkship time (range, 0 to 30 percent) in HMOs or managed-care settings, and residents reported that they spent 5.8±18.4 percent of their clinical time (range, 0 to 100 percent) in these settings. On a 0-to-10 scale, with 0 indicating no exposure and 10 extremely thorough exposure, fourth-year students and residents rated the extent of their exposure to managed care at 3.6±2.6 and 4.4±3.3, respectively.

A total of 75.4 percent of deans reported that their medical schools offered managed-care courses or lectures to their students; 65.8 percent required students to take some managed-care courses. Overall, 49.5 percent of deans reported that their medical schools offered clinical experience in managed-care settings; 11.5 percent required students to complete a clinical rotation in a managed-care system.

Preparation for Managed-Care Practice

Deans rated their graduates' preparation for practice in managed-care settings at 5.8±1.9 on a 0-to-10 scale, with 0 indicating a complete lack of preparation and 10 as thoroughly prepared as possible. Using the same scale, fourth-year students' ratings of their preparation for managed-care practice (6.3±2.1) were lower than residents' ratings of their own preparation (6.8±2.2, P<0.01). For purposes of comparison, fourth-year students' ratings of their preparation to communicate with patients (8.7±1.2) and to analyze the medical literature critically (7.4±2.1) were significantly higher than their ratings of their preparation for practice in managed-care systems (P< 0.001). Similarly, residents' ratings of their preparation for communicating with patients (9.0±1.3) and analyzing the medical literature critically (7.8±1.8) were also higher than their ratings of their preparation for managed-care practice (P<0.001). Fourth-year students and residents who reported any exposure to managed-care practice rated themselves better prepared for practice in managed-care systems than did those with no exposure (7.1 vs. 6.2, P< 0.001). Among faculty members, ratings of their own preparation for practice in managed-care settings differed according to their specialty orientation. Primary care faculty members and department chairs reported better preparation for practice in managed care than their specialist counterparts (7.4 vs. 6.1, P<0.001).

Knowledge of Managed Care

On a 0-to-10 scale, with 0 indicating almost no knowledge and 10 an extremely high level of knowledge, fourth-year students and residents rated their knowledge of managed care at 6.0±2.7 on a local level and 5.5±2.4 on a national level. As compared with fourth-year students and residents who reported spending no clinical time in managed-care settings, those who reported any clinical training in managed-care settings reported significantly higher levels of knowledge of local managed-care plans (6.7 vs. 5.5, P<0.001) and a trend toward higher levels of knowledge of managed care nationally (5.7 vs. 5.3, P=0.01). Faculty members' scores for their own knowledge of local and national managed care were 6.5±3.0 and 5.8±2.7, respectively.

This 1997 study of a national sample of medical school students, residents, faculty members, and deans documents widespread negative views about the effect of managed care on clinical care, teaching, research, and the quality of professional life. Specialists, who in their practices have experienced the bulk of changes resulting from managed care,²³ were consistently more negative than their counterparts in primary care about the effects of managed care. Although we found no consistent association between the competitiveness of the local managed-care market and the variables we measured, faculty members who cared for more patients enrolled in managed-care plans described more adverse effects on their teaching, research, and professional lives. Medical school deans appeared to be particularly negative about the effects of managed care.

Our data show that medical students and residents share the negative views toward managed care reported by faculty members and are heavily influenced by the faculty in developing their opinions. Students and residents confirmed that many of the messages they receive from their teachers about managed care are negative. Although students have some exposure to managed care in the medical school curriculum, both students and residents reported little personal experience with managed care in their clinical training.

Several limitations must be considered in interpreting these results. First, this study was undertaken to ascertain perceptions of managed care among students, residents, faculty members, and deans, because the reality of managed care differs from organization to organization and from city to city. Perceptions may be more important than actual experiences, since they create the culture and shape the discourse, expectations, and experiences of physicians and trainees in academic health care centers. Second, we did not define managed care for respondents and thus do not know how respondents conceived of managed care when answering survey questions. For example, in reporting exposure to managed care, students and residents may have considered only outpatient rotations in HMOs as experiences with managed care, even though many of their hospitalized patients may have been insured by managed-care organizations. Similarly, respondents may not have considered courses in health economics or health policy as courses related to managed care, even though such courses included discussions of managed-care systems. Third, although a majority of respondents favored a single-payer system of health care with universal coverage, the survey did not specify what delivery structure or financing method would underlie such a system. Finally, we excluded questions on attitudes toward managed care when there was agreement among respondents in a pilot survey that either managed care or fee-for-service care was clearly better than the other system. This method led to the exclusion of some items that favored managed care and some that favored fee-for-service medicine.

The negative views of specialist faculty members toward managed care might be viewed as arising from its adverse effects on their incomes and job security.²³ However, primary care faculty members, who are more likely to have benefited from changes related to managed care, also expressed reservations about its effects.

The deficiencies identified by the respondents in their preparation for practice in a managed-care setting and the concern they expressed about the capacity of managed care to meet health care needs may be interpreted as indicating the need to improve medical education in and about managed care. This strategy, however, may be ineffective when faculty members view managed care as negatively as their responses to this survey suggest. The negative attitudes toward managed care, the lack of emphasis on education related to managed care, and the perceived effects of managed care on the mission of academic medical centers and on the lives of the faculty may indicate a more fundamental concern about managed care itself. From this perspective, the apparent deficiencies in exposure to and preparation for managed-care practice may reflect reservations, resistance, or even frank opposition to managed care among faculty members and administrators at academic health centers.

In either case, a constructive strategy for supporting the education of students and residents and addressing the issues of concern to faculty members must be developed. Because negative attitudes toward managed care are pervasive within academic health centers, any efforts to address this problem must be made system-wide. Our study points to many opportunities for improving knowledge about and preparation for practice in the context of managed care on the part of students, residents, and faculty members. In addition, we believe that enhanced dialogue among public-policy experts, leaders of managed-care organizations, and leaders of academic health centers about how to provide high-quality care and improve medical education is an essential step in ensuring a well-prepared physician work force and supporting the missions of the academic health center in research, teaching, and clinical care.