The Effects of Organizational Structure on Primary Care Outcomes under Managed Care

Whatever form it ultimately takes, health care reform in the United States will probably include an expanded role for managed care organizations and systems [1]. What is not clear and needs to be better understood is how this restructuring of the market for health care will affect the delivery of primary care. There are many (the fictional Harry and Louise of the television commercials among them) who fear that an expanded role for managed care will make care less accessible and will disrupt the relationship between physician and patient. Available data suggest that this concern may be justified. Although they maintain certain overall cost advantages, managed care systems have historically fared poorly in primary care accessibility and patient satisfaction [2, 3]. However, this poor performance need not continue. It is possible to identify aspects of health care organizations that promote rather than inhibit primary care delivery. Close attention to identifying the optimal structure of primary care systems can prevent many of the problems inherent in large, complex organizations. I describe what is currently known about the relation between the organizational structure of managed care systems and the quality of the primary care within them. The literature included in this discussion includes all works identified in a search for the outcomes discussed. The relative scarcity of data suggesting possible advantages of large organizational systems in these outcomes reflects their scarcity in the literature identified. In medicine, quality has traditionally been considered to be synonymous with technical or clinical quality. With medicine's recent transformations, the meaning of quality has become considerably broader. The best medical care is applied with the highest technical skill and carried out in a humane, culturally sensitive, and coordinated manner. Quality will suffer when any of these components is lacking [4]. Donabedian [5] identifies two principal components as composing the quality of medical care: technical aspects of care and the interpersonal relationship between the provider and the patient. Technical quality is primarily reflected in clinical outcomes. Interpersonal processes of care, such as accessibility, continuity, and personal accountability, affect patient satisfaction with care [6]. Donabedian [5] also asks whether the cost of care should be included as a measure of quality. In light of the movement toward health care reform, this question seems now to have been answered in the affirmative. Optimal care balances clinical outcomes, satisfaction, and costs. Although Donabedian does not include provider satisfaction as part of his conception of the quality of care, there are several reasons to do so. No organized system of primary care will succeed without the support of its physicians. As described below, strong evidence suggests that patient satisfaction and the job satisfaction of physicians and other health care providers are closely linked. In evaluating the quality of primary care systems, then, four principal outcomes should be considered: clinical quality, patient satisfaction with care, physician (and other provider) satisfaction with the care process, and the cost of care. Others are addressing the question of clinical quality in managed care systems [7]. In this discussion, I focus on how the organizational characteristics of managed primary care systems such as size, complexity, and professional autonomy affect patient satisfaction, physician satisfaction, and cost. I first examine potential sources of patient dissatisfaction in large primary care organizations and then summarize what is known about physician satisfaction and the cost of physician care. Any policy-oriented discussion of the optimal structure of primary care systems is incomplete without consideration of these three outcomes. Donabedian makes one further point about the study of the quality of care. He states that knowledge about the relationship between structure and process (or between structure and outcomes) proceeds from the organizational sciences. These sciences are still relatively young, so our knowledge of the effects of structure is rather scanty. What we do know suggests that the relationship between structural characteristics and the process of care is rather weak [8]. However, Donabedian does not fully consider current knowledge derived from several decades of work in the field of organizations theory. It has been known for some time in this field that organizational structure powerfully affects outcomes. Only recently have such sociologic and economic perspectives been extended to include health care. The merging of social and medical perspectives can provide valuable insights for those involved in the delivery of health care and those responsible for managing it. Organizational Size and Complexity and Patient Satisfaction As organizations increase in size, work within them tends to become differentiated. Complex tasks are broken up into their constituent parts, with individual employees doing one specialized and simplified job [9-11]. Only managers have a complete view of the overall production process. However, managers typically do not actually participate in production. Their principal responsibility is one of coordination and control. Unique problems arise in managing organizational systems that produce services such as health care rather than manufactured goods. The diffuse and indistinct nature of health care, and the difficulty in quantifying or qualifying it, can lead to a high level of ambiguity in defining job responsibilities for employees [12]. Rather than simply measuring the number and quality of goods produced per hour as is often done for manufactured items, health care managers must establish somewhat arbitrary measures of output and worker efficiency. These control mechanisms tend to impede the provision of good service to patients. Forces such as these that develop within large organizations and interfere with internal organizational processes have been labeled transaction costs or X-inefficiencies [13, 14]. Newhouse [15] predicts that significant inefficiencies of this type will develop in large health care organizations. The process of providing care, which in the traditional physician's office involves only a few persons with shared responsibilities, becomes fragmented in larger organizations. Communication among and coordination of the various aspects of care become difficult. Aspects of care not involving the physician, such as registration, telephone advice, and ancillary diagnostic services, become dispersed throughout the organization. As physicians come to rely on these specialized organizational supports, they become removed from much of the actual care received by the patient and from the consequences of the interactions between the patient and many of the nonphysician employees. These employees spend their work time providing service to patients. The quality of that interaction affects the emotional atmosphere of work and employee satisfaction [16]. Unfortunately, good service is often contrary to organizational efficiency as defined and enforced by management [17]. Emphasizing service to the patient often compromises organizational efficiency. Caught in the stress of these conflicting expectations, employees may respond by withdrawing from personal involvement with or commitment to the needs of the patient, appearing to the patient as callous or unconcerned [18]. The effect of this conflict for health care employees in large organizations is especially significant in light of the social effects of large groups on individual members of the group. When an individual needs assistance, the willingness of an observer to offer that assistance is inversely related to the size of the group of observers in contact with the person in need [19]. Translated into the context of a health care organization, the willingness of any one employee to offer assistance to a patient in need decreases as the number of employees with whom the patient has contact increases. In addition, when employees are asked to perform tasks in a large group, their individual efforts sizably decrease compared with their efforts when working alone [20]. Thus, in large health care organizations we would expect to see a tradeoff between service and efficiency in the provision of primary care, with decreased patient satisfaction a likely result. In the following section, I describe actual empirical studies comparing patient satisfaction in alternative organizational structures of health care systems. Many of these studies confirm this prediction. Patient Satisfaction in Large Health Care Systems The results of several studies examining patient satisfaction with outpatient care in managed care settings are summarized in Table 1. Certain types of large health maintenance organizations (HMOs) have been shown to provide significant cost savings through lower rates of hospitalization and less frequent use of expensive technologies. However, they do so at the price of patient satisfaction with outpatient care [21]. In a study comparing a prepaid group practice organizational model with a traditional fee-for-service model, Tessler and Mechanic [22] found that patient satisfaction with care was significantly lower in the larger prepaid organization. Overall satisfaction was more strongly associated with access to care than with the perceived technical quality of care [22]. Sorensen and Wersinger [23] compared satisfaction with care in a large centralized HMO and a matched sample of patients receiving traditional fee-for-service care. Patients receiving care from an HMO were more satisfied with waiting time in the physician's office but were less satisfied with appointment availability and the interpersonal aspects of care [23]. Table 1. Summary of Patient Satisfaction with Outpatient Care in Health Maintenance Organizat