When it comes to signing contracts, managed care plans appear to discriminate against physicians who treat a majority of underserved patients, according to a study by health policy experts at UCSF. Almost a quarter of the physicians participating in the study said they had experienced either contract denial or termination from a managed care organization.

The analysis -- which involved primary care physicians in 13 major urban areas in California -- is reported in today's (March 4) issue of The Journal of the American Medical Association.

"What we found is certainly worrisome," said Andrew Bindman, principal investigator and director of the UCSF Primary Care Research Center at San Francisco General Hospital.

"The physicians who provide a disproportionate amount of care to the uninsured and to nonwhite patients were shown to be significantly less likely to have managed care patients, so rather than rewarding these physicians for their social responsibility, the market place seems to be excluding them," he added.

"If the penalty for caring for this population is exclusion, then more office-based physicians may decide they cannot afford to provide it. Managed care contracts are now a key element in their economic survival," he said.

Managed care organizations have begun to dominate the health insurance market over the past few years, but little is known about the problems physicians may be experiencing in gaining access to these networks, according to Bindman. There have been anecdotal reports about physician exclusion, but this is the first study to do a systematic evaluation, he said.

The UCSF research involved a random sample of 520 physicians, all of whom were in office-based private practice in the primary care specialties of family medicine, pediatrics, general internal medicine, or obstetrics/gynecology. They participated through written responses to a questionnaire.

"The high number of primary care physicians who had a contract denied or terminated -- 22 percent of study participants -- was a surprise," Bindman said. "It's likely that physician specialties that are oversupplied compared to primary care are experiencing even greater rates of denial and termination from managed care."

Based on the study, the UCSF research team concluded that managed care plans are selective about whom they choose for contracts, but the team found no systematic discrimination based on physician race, ethnicity, age or gender.

Philip Hopewell, associate dean for the UCSF School of Medicine at SFGH, called the findings disturbing. "By excluding physicians who care for large numbers of patients from underserved groups, managed care organizations are selecting for patients who have less severe and less frequent illness. This situation leaves public hospitals, such as SFGH, that have a mission to care for the sickest patients at a competitive disadvantage in a market-driven health economy," he added.

The JAMA article is titled "The Selection and Exclusion of Primary Care Physicians by Managed Care Organizations." The UCSF co-authors are Kevin Grumbach, Karen Vranizan, Deborah Jaffe and Dennis Osmond. The research was supported by a grant from The Robert Wood Johnson Foundation.

by Corinna Kaarlela

1st appeared 3/04/98

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