Patients Concerned About Insurer Influences

Originally published as Data Bulletin No. 17 by the Center for Studying Health System Change (HSC), June 2000. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Patients Concerned About Insurer Influences on Their Doctors

Legislative efforts to regulate managed care in the late 1990s reflected, in part, widespread consumer unease about how health plans influenced the doctor-patient relationship. Findings from the Center for Studying Health System Change showed that many consumers believed their physicians were influenced by insurers' rules -- yet these same consumers expressed strong trust that their own doctor prioritized their medical needs above other considerations.

Results from the 1998-1999 Community Tracking Study (CTS) Household Survey revealed that 44 percent of insured adults who had seen a doctor in the past 12 months or who had a doctor as their usual source of care agreed with the statement: "I think my doctor is strongly influenced by health insurance company rules when making decisions about my medical care." This percentage held steady between the 1996-1997 and 1998-1999 surveys, a noteworthy finding given the intensity of the managed care backlash during that period. At the same time, relatively few people -- about 7 percent in the 1998-1999 survey -- believed their doctor failed to put patients' needs first. Among those who felt insurers influenced their doctor, the figure was modestly higher at 12 percent, but still a clear minority.

Demographic Differences in Perception

Significant demographic differences emerged in how people perceived insurer influence on physicians, though demographic variation was less pronounced when it came to trust that doctors put patients first. These patterns changed little between survey rounds.

Income played a consistent role. As income rose, the share of people who believed their doctor was strongly influenced by insurance company rules declined steadily. More than half of people with family incomes below the poverty line agreed that their doctors were influenced by insurers, compared with 40 percent of those with incomes at least four times the poverty level. Across all income brackets, the percentage who felt doctors would not put their medical needs first remained very low.

Race and ethnicity were also significant factors. African Americans and Hispanics were far more likely to agree that their doctors were influenced by insurance rules (56 percent and 54 percent, respectively) compared with whites (40 percent). These racial and ethnic differences persisted after controlling for income and other demographic characteristics. Hispanics were also somewhat more likely than whites and African Americans to believe that their doctors might not put medical needs first when making treatment decisions.

Health status had a more modest effect. People in poorer health were slightly more concerned about insurer influence on their doctors. While the differences were small, those who reported worse health were also more likely to believe their doctor might not place medical needs above other considerations.

Policy Implications

The findings highlighted a tension at the heart of health care policy: the need to balance cost savings achieved by influencing physicians' decisions on referrals, tests, and treatments against concerns that insurer interventions might undermine the quality of care. UnitedHealthcare's announcement during this period that it would no longer require prior approvals for covered care reflected one attempt to address these concerns. The public clearly had an interest in how much insurers tried to influence doctors, but opinion was divided on whether plans had gone too far. For policy makers, the challenge was deciding whether and how to intervene -- reconciling consumers' worries about insurer influence with their strong, almost unshakeable confidence in their own physicians.

Data Source

This analysis drew on findings from two rounds of the Community Tracking Study Household Survey, a nationally representative telephone survey of the civilian, noninstitutionalized population. The 1996-1997 survey included nearly 33,000 families and 60,000 individuals; the 1998-1999 survey included about 32,000 families and 59,000 individuals. The analysis excluded people without health insurance. All comparisons and differences reported were statistically significant.

Sources and Further Reading

HSC Community Tracking Study Household Survey, 1996-1997 and 1998-1999. | Hargraves, J. Lee, Data Bulletin No. 17, Center for Studying Health System Change, June 2000.