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New Survey Shows That Providers and Health Plans Clash Often over Patient Care

Doctors and Nurses Give Plans Good Marks in a Few Areas, But Many Report Frequent Denials of Coverage and Adverse Health Consequences for Their Patients

Embargoed For Release Until:9:00 a.m. EDT, Wednesday, July 28, 1999

Contact: Missy Krasner or Matt James, 650-854-9400

MENLO PARK, CA – A survey of doctors and nurses released today sheds new light on how frequently health plans and care providers disagree about the appropriate care for patients, and what implications those disagreements have for patients’ health.

Almost nine out of ten doctors (87%) said that their patients have experienced health plan denials of coverage for health services over the last two years, with denials reported most frequently for prescription drugs (61% of doctors said they see denials for prescriptions they order on a weekly or monthly basis). Many doctors — between a third and two-thirds, depending on the type of denial — also reported that (in their judgement) health plan denials of drugs, hospital stays, diagnostic tests or referrals to specialists or mental health services resulted in adverse health consequences for their patients. About half of nurses (48%) said that within the last two years a health plan decision has resulted in a decline in health for their patients.

Two-thirds of doctors said they often or sometimes intervened with plans on their patients’ behalf. And these doctors said their interventions often led to a resolution in the patient’s favor, with plans responding positively 42% of the time, or compromising 21% of the time. Close to one-half of doctors (48%) and nurses (46%) said that they have exaggerated the severity of a patient’s condition to get coverage for medical care they felt was required by the patient.

“There is a great deal of inappropriate care in the health care system and it is the managed care industry that has taken on the unpopular job of controlling costs, but this level of conflict and administrative haggling between doctors and plans can’t be good for our health care system or for patients who are often caught in the middle,” said Drew Altman, Ph.D., president of the Kaiser Family Foundation.

Both doctors and nurses see the growing influence of managed care as having primarily negative effects on health care. Doctors cited increases in paperwork and nurses cited decreasing quality of care as the prime downsides. But both also gave more positive marks to health plans for preventive care and for practice guidelines and disease management protocols they find helpful.

The Survey of Physicians and Nurses is a national random survey of 1053 doctors and 768 nurses conducted by researchers at the Kaiser Family Foundation and the Harvard School of Public Health. The survey collected quantitative information from doctors and nurses about their non-elderly patients, as well as verbatim descriptions of patient experiences with health plan decisions. The survey reports doctors’ judgements on the impact of denials; health plans or independent reviewers might disagree with these judgements in some cases.

Provider Reports of Patient Experiences

The survey asked doctors and nurses for specific information about the nature and frequency of health plan decisions to deny coverage. The most frequent denials reported by doctors were for prescription drug coverage (61% said it occurred weekly or monthly — 33% weekly; 28% monthly), followed by denials for diagnostic tests (42% — 16% weekly; 26% monthly), overnight hospital stays (31% — 9% weekly; 22% monthly), referrals to specialists (29% — 10% weekly; 19% monthly); and referrals for mental health services (18% — 6% weekly; 12% monthly).

Among the doctors who reported that their patients experienced denials, many said that a decline in health status had occurred as a result:

  • Mental Health – of those doctors who reported a denial, 65% said their most recent denial had resulted in a “very serious” (16%) or “somewhat serious” (49%) health decline;
  • Referrals to Specialists – 50% said their most recent denial resulted in a “very serious” (12%) or “somewhat serious” (38%) health decline;
  • Diagnostic Tests – 46% said their most recent denial resulted in a “very serious” (8%) or “somewhat serious” (38%) health decline;
  • Overnight Hospital Stays – 39% said their most recent denial resulted in a “very serious” (6%) or “somewhat serious” (33%) health decline; and
  • Prescription Drugs – 37% said their most recent denial had resulted in a “very serious” (5%) or “somewhat serious” (32%) health decline

Of the 48% of nurses who said a health plan decision over the last two years had resulted in a decline in a patient’s health, almost two-thirds said it happened on a weekly or monthly basis (26% weekly, 37% monthly).

In order to get patients coverage for care they thought was medically necessary, 48% of doctors reported that within the last two years they had exaggerated the severity of a patient’s condition (including 5% who said they did it often, 21% who said they did it sometimes, and 22% who said they did it rarely; 51% said they never did it at all).

“The detailed descriptions of denials of coverage provided by doctors underscore the challenges of addressing the unique needs of individual patients within the rules of managed care,” said Dr. Karen Donelan, assistant professor at the Harvard School of Public Health.

Attitudes of Physicians and Nurses

Most health care providers see the growing influence of managed care as having primarily negative effects on health care:

  • 95% of doctors and 92% of nurses said that managed care has increased the amount of administrative paperwork for providers and patients;
  • 86% of doctors and 82% of nurses said that managed care has decreased their patients’ ability to see medical specialists;
  • 83% of doctors and 85% of nurses said managed care has decreased the amount of time they spent with patients; and
  • 72% of doctors and 78% of the nurses said that managed care has decreased the quality of care for people who are sick

Though many providers also see positive aspects in managed care:

  • 68% of the doctors and 51% of nurses said that managed care has increased the use of practice guidelines and disease management protocols in patient care; and
  • 45% of doctors and 42% of nurses said that managed care has increased the likelihood that patients would get preventive services

Many doctors also reported that health plans sometimes acted to help them improve patient care in their own practices: 47% said that health plans “often or sometimes” provide them with innovative screening tools to help them manage their patients’ illness; 33% said that plans “often or sometimes” help them encourage patients to lead healthier lives; and 25% said that plans “often or sometimes” provide them with clinical data to help better manage their patients’ care.

In reflecting on their own experiences in medicine, 58% of doctors said spending too much time on administration and not enough time with patients was a “great concern.” Fewer said not having enough clinical autonomy (47%) and not making as much money as they had planned (26%) were also “great concerns.” Almost seven in ten nurses (69%) cited inadequate staffing levels as a “great concern.” Fewer pointed to not having enough clinical autonomy (33%), inadequate training to cope with changes (28%) and not making as much money as they had planned (26%).

Most doctors (79%) and nurses (70%) said their views of managed care were shaped primarily by their own experiences as health care providers. Fewer cited reports from professional organizations (31% for doctors; 29% for nurses) and the media (22% for doctors; 27% for nurses) as major influences. Nurses were more likely than doctors to say they were influenced a great deal by their personal experiences as patients (38% vs. 23%) or by reports from friends and family members (47% vs. 39%).

Views Are Not Homogenous

Physicians views and experiences with managed care varied substantially by specialty designation and practice setting. Specialists (71%) were more likely to say that managed care had a negative impact on patients than primary care physicians (58%). Doctors who contract with multiple health plans (74%) were also more likely than doctors who work predominantly with a single HMO (52%) to report negative effects of managed care on patients.

Methodology

The 1999 Survey of Physicians and Nurses was designed and analyzed by researchers at the Kaiser Family Foundation and the Harvard School of Public Health. The survey was administered by mail by the National Opinion Research Center to a national random sample of 1053 physicians and 768 nurses nationwide between February 11 and June 5, 1999. Because fewer Medicare beneficiaries are in managed care plans, the survey asked doctors and nurses only about their experiences with patients under 65 years of age. The physician sample was drawn from the American Medical Association’s Masterfile and included physicians who indicate that they care for patients 20 or more hours each week. The sample was proportionately stratified to represent primary care physicians (general and family practitioners, general internists, pediatricians) and specialists (medical specialists and surgeons). The sample of registered nurses was drawn from a list provided by Medical Marketing Services, Inc. that was compiled from state nurse registries and other sources for use in surveys of nurses. Respondents were ineligible if they had not cared for patients in the year prior to the survey. The survey data are weighted by age, gender and region to be representative of national samples of patient care physicians and registered nurses and to account in part for non-response.

The survey collected quantitative information about physicians’ and nurses’ experiences with and attitudes towards health plans, particularly as it relates to patient care. The survey also collected verbatim responses from physicians and nurses in order to assess their judgements about the consequences of health plan denials for their patients. Reported verbatim responses were randomly selected from a total of 601 responses provided by physicians and 365 responses provided by nurses. Data presented on the consequences of health plan denials represents the judgements of the physicians surveyed, not independent clinical reviews. The maximum margin of sampling error for responses in a survey of 1,053 physicians is +/- 3% and for 768 nurses is +/- 4%. Estimates from smaller subgroups may be subject to higher margins of error based on the subgroup size.

The Kaiser Family Foundation, based in Menlo Park, California, is an independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. Copies of the questionnaire and topline data for the findings reported in this release are available online at www.kff.org or by calling the Foundation’s Publications Request Line at 1-800-656-4533 (ask for document # 1503).

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