Back in the Driver's Seat: Specialists Regaining Autonomy

Originally published as Tracking Report No. 7 by the Center for Studying Health System Change (HSC), January 2003. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Between 1997 and 2001, the share of medical specialists reporting greater freedom to make clinical decisions that met their patients' needs rose significantly, far outpacing gains among primary care physicians (PCPs), according to findings from the Center for Studying Health System Change. Specialists also grew more likely to believe they could make patient-centered clinical decisions without taking a hit to their income and could maintain lasting relationships with patients that supported high-quality care. Among PCPs, however, attitudes on these measures changed very little over the same period. These shifts in physician perception likely reflected the managed care backlash of the late 1990s, when health plans responded to pressure from consumers and physicians by offering broader provider networks and easing restrictions on care.

Specialists' Clinical Autonomy Increased

One defining feature of managed care in the mid-1990s was its heavy emphasis on primary care and tight restrictions on access to specialty services. The gatekeeper model -- in which a primary care physician controlled patients' access to specialists -- became almost synonymous with managed care itself. Requirements like preauthorization for referrals and diagnostic tests led physicians to report feeling less autonomous in caring for their patients. Specialists bore the brunt of these controls and were less likely than their primary care colleagues to say they had the freedom to make clinical decisions that met patients' needs.

Under regulatory and market pressure in the late 1990s, many health plans began loosening restrictions on care and broadening provider networks, often resulting in fewer controls on the use of medical services. This made it easier for patients to see specialists and for physicians to order tests and referrals. Between 1997 and 2001, the proportion of specialists who agreed they could freely make clinical decisions jumped by 13 percentage points, from 72.7 percent to 85.7 percent. Among PCPs, the corresponding figure barely moved, holding steady at roughly 86 percent across the same surveys. By 2001, equal proportions of PCPs and specialists reported having clinical autonomy.

The increase in perceived clinical autonomy among specialists coincided with a growing belief that making the right clinical decisions would not hurt their bottom line. Between 1997 and 2001, the share of specialists who agreed they could act in patients' best interests without reducing their income rose from 68.6 percent to 79.6 percent. The corresponding figures for PCPs remained essentially flat. The decline in capitated contracting -- where managed care organizations pay physicians a fixed monthly amount per patient -- likely contributed to this shift. Among specialists with managed care contracts, the proportion receiving at least some revenue from capitation fell from 45 percent to 36.4 percent.

Differing Views on Continuity and Communication

Clear divergences also emerged in how specialists and PCPs viewed their ability to maintain continuous relationships with patients and communicate effectively with each other. Specialists had historically reported more difficulty sustaining ongoing patient relationships. Yet between 1997 and 2001, the share of specialists who agreed they could maintain continuity with patients surged by more than 15 percentage points, from 57.9 percent to 73.1 percent. PCPs saw almost no change. As many health plans dropped referral requirements and allowed direct access to specialists, it became easier for patients to establish and maintain relationships with their specialist physicians.

On the question of communication, countervailing trends appeared. In each survey period, PCPs were more likely than specialists to believe that communication between them was sufficient to ensure high-quality care. However, the percentage of PCPs reporting adequate communication declined from 86.5 to 80.8 percent between 1997 and 2001, while the corresponding percentage among specialists edged up. Loosened restrictions on direct specialist access, which allowed patients to bypass PCPs, may help explain these divergent patterns.

Role of Managed Care Participation

The differences between specialists' and PCPs' perceptions persisted when researchers accounted for the level of managed care participation. Generally, physicians deriving less revenue from managed care reported greater autonomy, better patient continuity, and more adequate time with patients. Comparing physicians in the top third of managed care revenue with those in the bottom third revealed that the gap in specialists' sense of autonomy based on managed care involvement shrank dramatically, from 6 percentage points in 1997 to just 2 percentage points by 2001. For PCPs, the gap actually widened slightly over the same period.

One area where PCPs and specialists converged was time with patients. Both groups reported declining adequacy of visit time, and physicians with lower managed care revenues were consistently 10 to 12 percentage points more likely to report having enough time with patients than their heavily managed care-dependent colleagues.

Implications of Greater Specialist Autonomy

As managed care became less intrusive, physicians -- especially specialists -- reported greater professional autonomy, a value closely associated with higher career satisfaction and the belief that greater independence leads to better patient care. But these gains came with tradeoffs. Loosened care management restrictions, increased enrollment in plans allowing direct access to specialists, and fewer capitated contracts were likely to drive up health care utilization, costs, and insurance premiums. Higher premiums would leave more people uninsured, and care for the uninsured would suffer. Another cost was the potential erosion of coordination and communication between primary care physicians and specialists that managed care had helped to foster.

The health care system would continue searching for ways to enhance physicians' professional abilities while keeping costs in check. Patients and specialists clearly preferred a lighter touch from managed care. Whether patients, employers, and taxpayers were willing to bear the costs of completely unmanaged health care was far less certain. The balance among access, specialist autonomy, and cost seemed likely to shift again.

Sources and Further Reading

HSC Community Tracking Study Physician Survey, 1996-97, 1998-99, and 2000-01. | Stoddard, Jeffrey J., et al., "Managed Care, Professional Autonomy, and Income," Journal of General Internal Medicine, Vol. 16, No. 10 (October 2001). | Draper, Debra A., et al., "The Changing Face of Managed Care," Health Affairs, Vol. 21, No. 1 (2002). | Strunk, Bradley C., and James D. Reschovsky, Kinder and Gentler: Physicians and Managed Care, 1997-2001, Tracking Report No. 5, HSC (November 2002).