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Managed care patients' concerns about conflict of interest may be harming their relationship with their doctors

Managed care patients rarely ask doctors directly about conflict of interest. Yet, many doctors believe that patient concerns that doctors may withhold needed medical care from them due to pressures from insurers to reduce costs may be harming the doctor-patient relationship and damaging their own sense of professional worth. That's the conclusion of a study supported by the Agency for Healthcare Research and Quality (HS09982). Physicians should be alert to patients' implicit expressions of concern about conflicts of interest and practice communication techniques for responding to these concerns effectively, suggests Wendy Levinson, M.D., of the University of Chicago.

Dr. Levinson and her colleagues audiotaped four in-depth focus group sessions held in May 2000, with 39 community physicians in Portland, OR, a highly penetrated managed care market. As part of the discussions, they also asked the physicians to listen to an interchange between a patient with headaches who wanted magnetic resonance imaging (MRI) to rule out cancer, despite the expense of the test, and to evaluate eight different hypothetical responses that physicians might make to the patient.

Four major themes surfaced multiple times throughout the discussion groups. Managed care patients rarely asked their physicians directly about conflicts of interest; instead, they raised the topic indirectly, for example, by asking the doctor for repeated explanations of why a specific referral or diagnostic test was unnecessary. Most of the physicians believed that patient concern about conflicts of interest was leading to worrisome changes in the doctor-patient relationship. Rather than being seen as a trusted source of health care advice, physicians believed some patients saw them as agents of the health plan, a perception that diminished their sense of professional worth. In response to the patient's MRI request, physicians preferred strategies that addressed the worries of the patient or that identified a common goal through negotiation.

See "Patient-provider discussions about conflicts of interest in managed care: Physicians' perceptions," by Rita Gorawara-Bhat, Ph.D., Thomas H. Gallagher, M.D., and Dr. Levinson, in the August 2003 American Journal of Managed Care 9, pp. 564-571.

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