Trust in managed care organizations

Two basic criticisms of managed care are that it erodes patient trust in physicians and subjects physicians to incentives and pressures that compromise the physician's fiduciary obligation to the patient. In this article, I first distinguish between status trust and merit trust, and then argue (1) that the value of status trust in physicians is probably over-rated and certainly underdocumented; (2) that erosion of status trust may not be detrimental if accompanied by an increase in well-founded merit trust; and (3) that under conditions of managed care the physician's commitment to traditional medical ethics cannot serve as an adequate basis for merit trust. Next, drawing on an analogy between managed care organzations and politics, I argue that (4) the most appropriate basis for merit trust in managed care is a conception of organizational legitimacy that includes procedural justice, empowerment of constructive criticism within the organization, and organizational accommodation of the noninstrumental commitment to patient well-being that is distinctive of medical professionalism. I then explore the conditions necessary for robust competition for merit trust among managed care organizations and indicate the kinds of public policies needed to facilitate such competition. Finally, I show how the account of organization-based merit trust can accommodate the special fiduciary obligation of medical professionals, without indulging in the delusion that it is the physician's fiduciary obligation always to provide all care that is expected to be of any net benefit to the patient.     

Evaluation of the Fort Bragg managed care experiment

Conclusion On the plus side, this study is a step forward. With a very specific population, it demonstrates that, with a moderate increase in communitybased services, fewer children need to be removed from their families and sent to residential treatment centers and psychiatric hospitals. On the other hand, it is only a step and, until we conduct more controlled, comparison studies in non-military communities and employ a more extensive array of innovative, community-based services, we run the risk of returning to a service delivery system that has proven to be so ineffectual in the past.     

Case vignette: the vicissitudes of managed care

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?     

Getting black kids into college

The gap between black and white in college enrollment is widening. The guidance counselor plays a key role in the drive to eliminate the differences between the races in preparation for college and to secure the scholarships and grants necessary for enrollment. Comparability in enrollment means about 850,000 black students on college campuses; about 400,000 are there now. Comparability in 1976 will mean about a million black students enrolled. Master Counselors are required for this job, both to work with the children and to press for more federal aid in this area.     

Considerations for ethical practice in managed care

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making.     

State regulation of managed care: fragments of reform

State legislatures consider numerous bills to regulate managed care organizations. After identifying the legal, political, and economic barriers to state reform efforts, the paper assesses recent types of state regulation, particularly mandated benefits and disclosure requirements. Two prerequisites to future reform, coalition building and the diffusion of information about managed care, are analyzed.     

Embedding instructive feedback into teacher-student interactions during independent seat work

The effects of embedding a constant time delay procedure into an independent seat work activity and using instructive feedback were evaluated in this study. Seven students with mild disabilities participated in the study that occurred in their special education classroom. A multiple probe design across sets of target behaviors was used, and students' responses to instructive feedback stimuli were evaluated during each probe condition. The procedures were implemented with a high degree of fidelity, and the results indicate that (a) the students acquired the target behaviors taught with the constant time delay procedure that was embedded into independent seat work, and (b) the students acquired some but not all of the responses to the instructive feedback stimuli. These findings are discussed in terms of using instructive feedback in classrooms and future research on instructive feedback.     

Conflict across organizational boundaries: managed care organizations versus health care providers

This research examined conflicts that occur across organizational boundaries, specifically between managed care organizations and health care providers. Using boundary spanning theory as a framework, the authors identified 3 factors in the 1st study (30 interviews) that influence this conflict: (a) organizational power, (b) personal status differences of the individuals handling the conflict, and (c) their previous interactions. These factors affected the individuals' behavioral responses or emotions, specifically anger. After developing hypotheses, the authors tested them in a 2nd study using 109 conflict incidents drawn from 9 different managed care organizations. The results revealed that organizational power affects behavioral responses, whereas status differences and previous negative interactions affect emotions.