BOX 2.2 Defining Managed Care

Although managed care has a long history in the United States, adoption of the federal Health Maintenance Organization Act in 1973 (as well as the term "health maintenance organization") marked the beginning of an era of accelerating growth for the managed care industry. In the 1970s and 1980s, HMOs typically were one of four distinct types:

  1. staff-model HMOs hired and supervised salaried physicians;
  2. group-model HMOs contracted with a single group of physicians without directly hiring them;
  3. independent practice association (IPA) models contracted with individual physicians or small groups in private practice and often arose when groups of physicians affiliated for the purpose of securing contracts;
  4. network HMOs contracted with two or more groups and were largely centrally organized as a means of securing discounted contracts with providers.
  5. Currently, this typology fails to describe accurately new forms of managed care. Many new systems now have components of both IPAs and groups, and share many of the same physician groups and intermediary organizations (e.g., IPAs). Most managed care organizations now have multiple options or "products" from which consumers can choose. Thus, the evolution of health care organizations has surpassed the current taxonomy, and even experienced observers of the health care system cannot adequately distinguish different health plans from one another.

    SOURCE: Landon et al., 1998.

A key concern of individuals with cancer is how they access cancer care specialists. In managed care systems, access to oncology specialists is often through a "gatekeeper," a primary care provider who authorizes referrals to specialists. In recent years, nearly one-third of primary care physicians report an increase in the severity and complexity of patient conditions they care for without referring to a specialist (St. Peter et al., 1997). Oncologists have expressed concerns that delays in referrals from primary care providers in managed care settings can negatively affect the outcome of therapy (Mortensen, 1997). While there are public concerns about access to specialists within managed care, there is little information on how managed care has affected oncology referral patterns. Furthermore, it is not entirely clear what the respective roles of primary care physicians and specialists should be in the provision of some aspects of care (e.g., follow-up care). The limited available evidence on the effect of provider specialization on quality is reviewed in Chapter 5.

Access to treatments and procedures has also changed in recent years. Utilization review has become a standard feature of both conventional and managed care. In a 1995 national survey, physicians said that on average, 59 percent of their patients were reviewed for length of stay, 45 percent for site of care, and 39 percent for the appropriateness of treatment. Although utilization review is common, denials of recommended procedures or referrals to specialists are relatively rare. Physicians reported that only 1 percent of recommended surgical procedures and 3 percent of referrals to specialists were ultimately denied (Remler et al., 1997).



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