"We used relatively straightforward, common conditions that offered at least some degree of treatment uncertainty," said Margaret Chesney, Ph.D., UCSF professor of medicine and co-author of the paper.
The percentage of physicians who recommended an indicated test or referral varied with the patient scenario. In all cases, however, physicians working under the assumption of the most restrictive managed care plan said they would order fewer services than physicians working under the assumption of a fee-for-service plan.
For example, one of the scenarios depicted a 56 year-old-woman suffering from low back pain for six weeks. According to national guidelines, the woman should be given a spinal X-ray or an orthopedic referral to evaluate for cancer or infection. When the patient was covered by the strictest managed care plan, 14 percent of physicians failed to recommend an X-ray or an appropriate referral. In comparison, 6 percent of physicians failed to prescribe the recommended treatment when the patient was covered on a fee-for-service basis.
A second scenario gave more startling results. When the recommended treatment included an upper endoscopy to look for the presence of a stomach ulcer or tumor, 50 percent of physicians operating under the strictest managed care plan did not order the endoscopy. But even under a fee-for-service plan, 39 percent of physicians failed to recommend the procedure.
"Because there has been concern in the medical community that financial incentives in managed care will lead physicians to withhold necessary services, we wanted to see if managed care members were getting sub-optimal care," said Pantilat. "We did see a tendency toward offering fewer services to managed care patients, but we also found that a significant number of all physicians did not follow nationally accepted guidelines for care, regardless of the incentives."