Am J Psychiatry 1996; 153:256-260
Copyright © 1996 by American Psychiatric Association
Managed care constraints on psychiatrists' hospital practices: bargaining power and professional autonomy
M Schlesinger, RA Dorwart and SS Epstein
Mental Health Policy Working Group, Malcolm Wiener Center for Social Policy, John F. Kennedy School of Government, Harvard University, Cambridge, MA 02138, USA.
OBJECTIVE: The increasing involvement of insurers and hospitals in
monitoring patient care is encroaching on the psychiatrist's autonomy in
making clinical decisions. This study examined the prevalence of
constraints on psychiatric inpatient practices, as well as how
characteristics of psychiatrists affect the type and the degree of these
external pressures. METHOD: About 2,500 psychiatrists with active hospital
affiliations were surveyed by mail, as a subset of APA's 1988 national
survey of psychiatrists. They were questioned about whether the hospital or
insurers had pressured them to change their inpatient practices or had
attempted to discourage admission of certain types of patients.
Characteristics of the psychiatrists' background, available from the main
survey, were used as independent variables in a set of regression models,
with frequency of different constraints as the dependent variables.
RESULTS: More than three quarters of those surveyed reported pressure from
insurers for early discharge; nearly two-thirds said hospitals limited
length of stay; and about half had been discouraged from admitting severely
ill patients, the uninsured, or Medicaid recipients. Characteristics of
psychiatrists, such as length of time in practice, income, sex, and medical
school education outside the United States, were associated with the
prevalence of external pressures. CONCLUSIONS: Constraints on
psychiatrists' practices are widespread. Their ability to resist pressures
depends on their bargaining power, which seems to be lowest for those who
have relatively little experience, who are female, or who have gone to
medical school outside the United States. Psychiatrists appear to be
willing to trade off more constraints for higher incomes. Severely ill
patients and those with little or no insurance are more likely than others
to be affected by these limits on psychiatrists' autonomy.
