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January 25, 1995, Vol 273, No. 4 >
ARTICLE | January 25, 1995

Preserving the Physician-Patient Relationship in the Era of Managed Care FREE

Ezekiel J. Emanuel, MD, PhD; Nancy Neveloff Dubler, LLB
[+] Author Affiliations

Reprint requests to Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115 (Dr Emanuel).


JAMA. 1995;273(4):323-329. doi:10.1001/jama.1995.03520280069043
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References

Even without comprehensive health care reform legislation, the US health care system is undergoing significant changes. Probably the most important change is the expansion of managed care with significant price competition. One of the major concerns about this change is the effect of managed care on the physician-patient relationship. To provide a normative standard for evaluating the effect of changes, we need an ideal conception of the physician-patient relationship. This ideal can be summarized by six C's: choice, competence, communication, compassion, continuity, and (no) conflict of interest. For the 37 million uninsured Americans there is little chance of realizing the ideal physician-patient relationship, since they lack the choice of practice setting and physician, receive care in a rushed atmosphere that undermines communication and compassion, and have no continuity of care. While many insured Americans may believe they have an ideal physician-patient relationship, the relationship is threatened by lack of a regular assessment of competence, by financial incentives that undermine good communication, and by the persistence of conflict of interest. The shift to managed care may improve the choice of practice settings, especially in sections of the country that currently lack managed care; increase choice of preventive services; make quality assessments more routine; and improve communication by making greater use of primary care physicians and nonphysician providers. However, the expansion of managed care and the imposition of significant cost control have the potential to undermine all aspects of the ideal physician-patient relationship. Choice could be restricted by employers and by managed care selection of physicians; poor quality indicators could undermine assessments of competence; productivity requirements could eliminate time necessary for communication; changing from one to another managed care plan to secure the lowest costs could produce significant disruption in continuity of care; and use of salary schemes that reward physicians for not using medical services could increase conflict of interest.

(JAMA. 1995;273:323-329)

REFERENCES

1 +
Miller RH, Luft HS.  Managed care plan performance since 1980. JAMA . 1994;;271:1512-1519.
2 +
Schwartz WB, Mendelson DN.  Why managed care cannot contain hospital costs—without rationing. Health Aff (Millwood) . 1992;;11:100-107.
3 +
Moran DW, Wolfe PR.  Can managed care control costs? Health Aff (Millwood) . 1991;;10:120-128.
4 +
Fox PD, Wasserman J.  Academic medical centers and managed care. Health Aff (Millwood) . 1993;; 12:85-93.
5 +
Eckholm E.  A town loses its hospital in the name of cost control. New York Times . (September 26) , 1994;:A1.
6 +
Weber M.  The fundamental concepts of sociology.  In: Parsons T, ed. The Theory of Social and Economic Organizations . New York, NY: The Free Press; 1947;:87-157.
7 +
Macklin R. Enemies of Patients . New York, NY: Oxford University Press Inc; 1993;: chaps 1,5,7,11 .
8 +
Brody H. The Healer's Power . New Haven, Conn: Yale University Press; 1992;: chaps 4-8 .
9 +
Emanuel EJ, Emanuel LL.  Four models of the physician-patient relationship. JAMA . 1992;;267: 2221-2226.
10 +
Brock D.  The ideal of shared decision-making between physicians and patients. Kennedy Inst J Ethics . 1991;;1:28-47.
11 +
Campbell JD, Mauksch HO, Meikirk HJ, Hosokawa MC.  Collaborative practice and provider styles of delivering health care. Soc Sci Med . 1990;; 30:1359-1385.
12 +
Beauchamp T, Childress J. Principles of Biomedical Ethics . 3rd ed. New York, NY: Oxford University Press; 1989;: chaps 3-5, 7 .
13 +
Kass LR. Toward a More Natural Science . New York, NY: The Free Press; 1988;: chaps 6-9 .
14 +
Appelbaum PS, Lidz C, Meisel A. Informed Consent: Legal Theory and Clinical Practice . New York, NY: Oxford University Press Inc; 1987;.
15 +
Siegler M.  The profession of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony. Arch Intern Med . 1985;;145: 713-715.
16 +
Katz J. The Silent World of Doctor and Patient . New York, NY: The Free Press; 1984;.
17 +
Making Health Care Decisions . Washington, DC: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research; 1982;.
18 +
Veatch RM. A Theory of Medical Ethics . New York, NY: Basic Books Inc Publishers; 1980;:pts 2 and 3.
19 +
Szasz TS, Hollender MH.  The basic models of the doctor-patient relationship. Arch Intern Med . 1956;;97:585-592.
20 +
Rawls J. Political Liberalism . New York, NY: Columbia University Press; 1993;;pt 1.
21 +
Dworkin R. Taking Rights Seriously . Cambridge, Mass: Harvard University Press; 1977;: chaps 2-4 .
22 +
Emanuel EJ. The Ends of Human Life: Medical Ethics in a Liberal Polity . Cambridge, Mass: Harvard University Press; 1991;: chap 1 .
23 +
The Kaiser/Commonwealth Fund Second National Health Insurance Survey. November 10,1993.
24 +
Blendon RJ, Knox RA, Brodie M, Benson JM, Chervinsky G.  Americans compare managed care, Medicare, and fee for service. J Am Health Policy . 1994;;4:42-47.
25 +
Sofaer S.  Informing and protecting consumers under managed competition. Health Aff (Millwood) . 1993;;12( (suppl) ):76-86.
26 +
Ingelfinger FJ.  Arrogance. N Engl J Med . 1980;; 304:1507.
27 +
Marzuk PM.  The right kind of paternalism. N Engl J Med . 1985;;313:1474-1476.
28 +
Applegate WB.  Physician management of patients with adverse outcomes. Arch Intern Med . 1986;;146:2249-2252.
29 +
Ware J, Snyder M.  Dimensions of patient attitudes regarding doctors and medical care services. Med Care . 1975;;13:669-682.
30 +
Woolley FR, Kane RL, Hughes CC, Wright DD.  The effects of doctor-patient communication on satisfaction and outcome of care. Soc Sci Med . 1978;;12:123-128.
31 +
Hickson GB, Clayton EW, Githens PB, Sloan FA.  Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA . 1992;;267:1359-1363.
32 +
Feilich B.  The death of a baby: neither forgiven nor forgotten. JAMA . 1992;;268:1413-1414.
33 +
Spiro H, McCrea-Curnen MG, Peschel I, St James D, eds. Empathy and the Practice of Medicine . New Haven, Conn: Yale University Press; 1993;: chaps 1-3, 8, 9, 13-16 .
34 +
Jonsen A. The New Medicine and the Old Ethics . Cambridge, Mass: Harvard University Press; 1990;.
35 +
Tarasoff v Regents of the University of California et al, 131 Cal Rptr 14 (1976).
36 +
McIntosh v Milano, 168 NJ 466 (1979).
37 +
Council on Ethical and Judicial Affairs, American Medical Association.  Conflict of interest: physician ownership of medical facilities. JAMA . 1992;; 267:2366-2369.
38 +
Thompson D.  Understanding financial conflicts of interest. N Engl J Med . 1993;;329:573-576.
39 +
Rodwin M. Medicine, Money, and Morals . New York, NY: Oxford University Press Inc; 1993;.
40 +
Hillman AL, Pauly MV, Kerstein JJ.  How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations? N Engl J Med . 1989;;321: 86-92.
41 +
Relman AS.  Dealing with conflicts of interest. N Engl J Med . 1985;;313:749-751.
42 +
Nelson C, Short K. Health Insurance Coverage, 1986-88 . Washington, DC: US Bureau of the Census; 1990;.
43 +
Lewin-Epstein N.  Determinants of regular source of health care in black, Mexican, Puerto Rican, and non-Hispanic white populations. Med Care . 1991;;29:543-557.
44 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
45 +
Burstin HR, Lipsitz SR, Brennan TA.  Socioeconomic status and risk for substandard medical care. JAMA . 1992;;268:2383-2387.
46 +
Iglehart JK.  The American health care system: teaching hospitals. N Engl J Med . 1993;;329:1052-1056.
47 +
Hoch S.  Tsongas's case. New York Times . (February 20) , 1992;:A23.
48 +
Laffel G, Berwick DM.  Quality in health care. JAMA . 1992;;268:407-409.
49 +
Kritchevsky SB, Simmons BP.  Continuous quality improvement: concepts and applications for physician care. JAMA . 1991;;266:1817-1823.
50 +
Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Wenrich MD.  Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med . 1989;;110:719-726.
51 +
Benson JA.  Certification and recertification: one approach to professional accountability. Ann Intern Med . 1991;;114:238-242.
52 +
Merkel WT, Margolis RB, Smith RC.  Teaching humanistic and psychosocial aspects of care. J Gen Intern Med . 1990;;5:34-41.
53 +
Beckman H, Frankel R, Kihm J, Kulesza G, Geheb M.  Measurement and improvement of humanistic skills in first year trainees. J Gen Intern Med . 1990;;5:42-45.
54 +
Levinson W, Roter D.  The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med . 1993;;8:318-324.
55 +
Perkins HS, Bauer RL, Hazuda HP, Schoolfield JD.  Impact of legal liability, family wishes, and other 'external factors' on physicians' life support decisions. Am J Med . 1990;;89:185-194.
56 +
Localio AR, Lawthers AG, Bengtson JM, et al.  Relationship between malpractice claims and cesarean delivery. JAMA . 1993;;269:366-373.
57 +
Rosenbach ML, Stone AG.  Malpractice insurance costs and physician practice 1983-1986. Health Aff (Millwood) . 1990;;9:176-185.
58 +
Woolhandler S, Himmelstein D.  The deteriorating administrative efficiency of the U.S. health care system. N Engl J Med . 1991;;324:1253-1258.
59 +
Gray B. The Profit Motive and Patient Care . Cambridge, Mass: Harvard University Press; 1991;:  chaps 5-8, 10, 11 .
60 +
Mitchell JM, Scott E.  Physician ownership of physical therapy services: effects on charges, utilization, profits, and service characteristics. JAMA . 1992;;268:2055-2059.
61 +
Igelhart JK.  The struggle between managed care and fee for service practice. N Engl J Med . 1994;;331:63-67.
62 +
Effects of Managed Care: An Update . Washington, DC: Congressional Budget Office; 1994;.
63 +
Managed Health Care: Effects on Employers' Costs Difficult to Measure . Washington, DC: US General Accounting Office; 1993;.
64 +
Bernstein AB, Thompson GB, Harlan LC.  Differences in rates of cancer screening by usual source of medical care: data from the 1987 National Health Interview Survey. Med Care . 1991;;29:196-209.
65 +
Retchin SM, Brown B.  The quality of ambulatory care in Medicare health mainenance organizations. Am J Public Health . 1990;;80:411-415.
66 +
Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM.  Comparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann Intern Med . 1991;;327:424-429.
67 +
Greenfield S, Nelson EC, Zubkoff M, et al.  Variations in resource utilization among medical specialties and systems of care. JAMA . 1992;;267:1624-1630.
68 +
Schroeder SA, Sandy LG.  Specialty distribution of U.S. physicians—the invisible driver of health care costs. N Engl J Med . 1993;;328:961-963.
69 +
Nurse Practitioners, Physicians' Assistants, and Certified Nurse Midwives: Policy Analysis . Washington, DC: Office of Technology Assessment; 1986;.
70 +
Freund C.  Research in support of nurse practitioners.  In: Mezey M, McGivern D, eds. Nurses and Nurse Practitioners: The Evolution to Advanced Practice . New York, NY: Springer Publishing Co Inc; 1993;.
71 +
Kavesh W.  Physician and nurse-practitioner relationships.  In: Mezey M, McGivern D, eds. Nurses and Nurse Practitioners: The Evolution to Advanced Practice . New York, NY: Springer Publishing Co Inc; 1993;.
72 +
Pear R.  Health insurance percentage is lowest in four Sun Belt states. New York Times . (October 6) , 1994;:A16.
73 +
Lewis DE.  Coping without coverage. Boston Globe . (May 5) , 1993;:45.
74 +
Lewis DE.  Union oks Boston gas accord. Boston Globe . (May 21) , 1993;:53.
75 +
Seitz R.  The political tea leaves point to medical networks. New York Times . (December 20) , 1992;:D10.
76 +
Pasternak J.  In-house doctors give some firms a health care remedy. Los Angeles Times . (July 11) , 1993;:A1.
77 +
Emanuel EJ, Brett AS.  Managed competition and the patient-physician relationship. N Engl J Med . 1993;;329:879-882.
78 +
Travis MR, Russell G, Cronin S.  Determinants of voluntary disenrollment. J Health Care Marketing . 1989;;9:75-76.
79 +
Hennelly VD, Boxerman SB.  Out-of-plan use and disenrollment: outgrowths of dissatisfaction with a prepaid group plan. Med Care . 1983;;21:348-359.
80 +
Sorenson AA, Wersinger RP.  Factors influencing disenrollment from an HMO. Med Care . 1981;; 19:766-773.
81 +
Clement DG, Retchin SM, Brown RS, Stegall MH.  Access and outcomes of elderly patients enrolled in managed care. JAMA . 1994;;271:1487-1492.
82 +
Henneberger M.  Managed care changing practice of psychotherapy. New York Times . (October 9) , 1994;:A1, A50.
83 +
Salem-Schatz S, Moore G, Rucker M, Pearson SD.  The case for case-mix adjustment in practice profiling: when good apples look bad. JAMA . 1994;; 272:871-874.
84 +
McNeil BJ, Pederson SH, Gatsonis C.  Current issues in profiling quality of care. Inquiry . 1992;; 29:298-307.
85 +
Green J, Passman LJ, Wintfield N.  Analyzing hospital mortality: the consequences of diversity in patient mix. JAMA . 1991;;265:1849-1853.
86 +
Burke M.  HCFA's Medicare mortality data: the controversy continues. Hospitals . 1992;:118,120,122.
87 +
Greenfield S, Aronow HU, Elashoff RM, Wantanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease. JAMA . 1988;;260:2253-2255.
88 +
Robinson ML.  Limitations of mortality data confirmed: studies. Hospitals . 1988;;62:23-24.
89 +
Baker LC, Cantor JC.  Physician satisfaction under managed care. Health Aff (Millwood) . 1993;; 12( (suppl) ):258-270.
90 +
Jelllinek MS, Nurcombe B.  Two wrongs don't make a right: managed care, mental health, and the marketplace. JAMA . 1993;;270:1737-1739.
91 +
Knox RA, Stein C.  HMO doctors want boss out in dispute on patient load. Boston Globe . (November 21) , 1991;:1, 27.
92 +
Freidson E.  Prepaid group practice and the new 'demanding patients.' Milbank Mem Fund Q . 1973;;51:473-488.
93 +
Schroeder JL, Clarke JT, Webster JR.  Prepaid entitlements: a new challenge for physician-patient relationships. JAMA . 1985;;254:3080-3082.
94 +
Brett AS.  The case against persuasive advertising by health maintenance organizations. N Engl J Med . 1992;;326:1253-1257.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Miller RH, Luft HS.  Managed care plan performance since 1980. JAMA . 1994;;271:1512-1519.
2 +
Schwartz WB, Mendelson DN.  Why managed care cannot contain hospital costs—without rationing. Health Aff (Millwood) . 1992;;11:100-107.
3 +
Moran DW, Wolfe PR.  Can managed care control costs? Health Aff (Millwood) . 1991;;10:120-128.
4 +
Fox PD, Wasserman J.  Academic medical centers and managed care. Health Aff (Millwood) . 1993;; 12:85-93.
5 +
Eckholm E.  A town loses its hospital in the name of cost control. New York Times . (September 26) , 1994;:A1.
6 +
Weber M.  The fundamental concepts of sociology.  In: Parsons T, ed. The Theory of Social and Economic Organizations . New York, NY: The Free Press; 1947;:87-157.
7 +
Macklin R. Enemies of Patients . New York, NY: Oxford University Press Inc; 1993;: chaps 1,5,7,11 .
8 +
Brody H. The Healer's Power . New Haven, Conn: Yale University Press; 1992;: chaps 4-8 .
9 +
Emanuel EJ, Emanuel LL.  Four models of the physician-patient relationship. JAMA . 1992;;267: 2221-2226.
10 +
Brock D.  The ideal of shared decision-making between physicians and patients. Kennedy Inst J Ethics . 1991;;1:28-47.
11 +
Campbell JD, Mauksch HO, Meikirk HJ, Hosokawa MC.  Collaborative practice and provider styles of delivering health care. Soc Sci Med . 1990;; 30:1359-1385.
12 +
Beauchamp T, Childress J. Principles of Biomedical Ethics . 3rd ed. New York, NY: Oxford University Press; 1989;: chaps 3-5, 7 .
13 +
Kass LR. Toward a More Natural Science . New York, NY: The Free Press; 1988;: chaps 6-9 .
14 +
Appelbaum PS, Lidz C, Meisel A. Informed Consent: Legal Theory and Clinical Practice . New York, NY: Oxford University Press Inc; 1987;.
15 +
Siegler M.  The profession of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony. Arch Intern Med . 1985;;145: 713-715.
16 +
Katz J. The Silent World of Doctor and Patient . New York, NY: The Free Press; 1984;.
17 +
Making Health Care Decisions . Washington, DC: President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research; 1982;.
18 +
Veatch RM. A Theory of Medical Ethics . New York, NY: Basic Books Inc Publishers; 1980;:pts 2 and 3.
19 +
Szasz TS, Hollender MH.  The basic models of the doctor-patient relationship. Arch Intern Med . 1956;;97:585-592.
20 +
Rawls J. Political Liberalism . New York, NY: Columbia University Press; 1993;;pt 1.
21 +
Dworkin R. Taking Rights Seriously . Cambridge, Mass: Harvard University Press; 1977;: chaps 2-4 .
22 +
Emanuel EJ. The Ends of Human Life: Medical Ethics in a Liberal Polity . Cambridge, Mass: Harvard University Press; 1991;: chap 1 .
23 +
The Kaiser/Commonwealth Fund Second National Health Insurance Survey. November 10,1993.
24 +
Blendon RJ, Knox RA, Brodie M, Benson JM, Chervinsky G.  Americans compare managed care, Medicare, and fee for service. J Am Health Policy . 1994;;4:42-47.
25 +
Sofaer S.  Informing and protecting consumers under managed competition. Health Aff (Millwood) . 1993;;12( (suppl) ):76-86.
26 +
Ingelfinger FJ.  Arrogance. N Engl J Med . 1980;; 304:1507.
27 +
Marzuk PM.  The right kind of paternalism. N Engl J Med . 1985;;313:1474-1476.
28 +
Applegate WB.  Physician management of patients with adverse outcomes. Arch Intern Med . 1986;;146:2249-2252.
29 +
Ware J, Snyder M.  Dimensions of patient attitudes regarding doctors and medical care services. Med Care . 1975;;13:669-682.
30 +
Woolley FR, Kane RL, Hughes CC, Wright DD.  The effects of doctor-patient communication on satisfaction and outcome of care. Soc Sci Med . 1978;;12:123-128.
31 +
Hickson GB, Clayton EW, Githens PB, Sloan FA.  Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA . 1992;;267:1359-1363.
32 +
Feilich B.  The death of a baby: neither forgiven nor forgotten. JAMA . 1992;;268:1413-1414.
33 +
Spiro H, McCrea-Curnen MG, Peschel I, St James D, eds. Empathy and the Practice of Medicine . New Haven, Conn: Yale University Press; 1993;: chaps 1-3, 8, 9, 13-16 .
34 +
Jonsen A. The New Medicine and the Old Ethics . Cambridge, Mass: Harvard University Press; 1990;.
35 +
Tarasoff v Regents of the University of California et al, 131 Cal Rptr 14 (1976).
36 +
McIntosh v Milano, 168 NJ 466 (1979).
37 +
Council on Ethical and Judicial Affairs, American Medical Association.  Conflict of interest: physician ownership of medical facilities. JAMA . 1992;; 267:2366-2369.
38 +
Thompson D.  Understanding financial conflicts of interest. N Engl J Med . 1993;;329:573-576.
39 +
Rodwin M. Medicine, Money, and Morals . New York, NY: Oxford University Press Inc; 1993;.
40 +
Hillman AL, Pauly MV, Kerstein JJ.  How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations? N Engl J Med . 1989;;321: 86-92.
41 +
Relman AS.  Dealing with conflicts of interest. N Engl J Med . 1985;;313:749-751.
42 +
Nelson C, Short K. Health Insurance Coverage, 1986-88 . Washington, DC: US Bureau of the Census; 1990;.
43 +
Lewin-Epstein N.  Determinants of regular source of health care in black, Mexican, Puerto Rican, and non-Hispanic white populations. Med Care . 1991;;29:543-557.
44 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
45 +
Burstin HR, Lipsitz SR, Brennan TA.  Socioeconomic status and risk for substandard medical care. JAMA . 1992;;268:2383-2387.
46 +
Iglehart JK.  The American health care system: teaching hospitals. N Engl J Med . 1993;;329:1052-1056.
47 +
Hoch S.  Tsongas's case. New York Times . (February 20) , 1992;:A23.
48 +
Laffel G, Berwick DM.  Quality in health care. JAMA . 1992;;268:407-409.
49 +
Kritchevsky SB, Simmons BP.  Continuous quality improvement: concepts and applications for physician care. JAMA . 1991;;266:1817-1823.
50 +
Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Wenrich MD.  Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med . 1989;;110:719-726.
51 +
Benson JA.  Certification and recertification: one approach to professional accountability. Ann Intern Med . 1991;;114:238-242.
52 +
Merkel WT, Margolis RB, Smith RC.  Teaching humanistic and psychosocial aspects of care. J Gen Intern Med . 1990;;5:34-41.
53 +
Beckman H, Frankel R, Kihm J, Kulesza G, Geheb M.  Measurement and improvement of humanistic skills in first year trainees. J Gen Intern Med . 1990;;5:42-45.
54 +
Levinson W, Roter D.  The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med . 1993;;8:318-324.
55 +
Perkins HS, Bauer RL, Hazuda HP, Schoolfield JD.  Impact of legal liability, family wishes, and other 'external factors' on physicians' life support decisions. Am J Med . 1990;;89:185-194.
56 +
Localio AR, Lawthers AG, Bengtson JM, et al.  Relationship between malpractice claims and cesarean delivery. JAMA . 1993;;269:366-373.
57 +
Rosenbach ML, Stone AG.  Malpractice insurance costs and physician practice 1983-1986. Health Aff (Millwood) . 1990;;9:176-185.
58 +
Woolhandler S, Himmelstein D.  The deteriorating administrative efficiency of the U.S. health care system. N Engl J Med . 1991;;324:1253-1258.
59 +
Gray B. The Profit Motive and Patient Care . Cambridge, Mass: Harvard University Press; 1991;:  chaps 5-8, 10, 11 .
60 +
Mitchell JM, Scott E.  Physician ownership of physical therapy services: effects on charges, utilization, profits, and service characteristics. JAMA . 1992;;268:2055-2059.
61 +
Igelhart JK.  The struggle between managed care and fee for service practice. N Engl J Med . 1994;;331:63-67.
62 +
Effects of Managed Care: An Update . Washington, DC: Congressional Budget Office; 1994;.
63 +
Managed Health Care: Effects on Employers' Costs Difficult to Measure . Washington, DC: US General Accounting Office; 1993;.
64 +
Bernstein AB, Thompson GB, Harlan LC.  Differences in rates of cancer screening by usual source of medical care: data from the 1987 National Health Interview Survey. Med Care . 1991;;29:196-209.
65 +
Retchin SM, Brown B.  The quality of ambulatory care in Medicare health mainenance organizations. Am J Public Health . 1990;;80:411-415.
66 +
Udvarhelyi IS, Jennison K, Phillips RS, Epstein AM.  Comparison of the quality of ambulatory care for fee-for-service and prepaid patients. Ann Intern Med . 1991;;327:424-429.
67 +
Greenfield S, Nelson EC, Zubkoff M, et al.  Variations in resource utilization among medical specialties and systems of care. JAMA . 1992;;267:1624-1630.
68 +
Schroeder SA, Sandy LG.  Specialty distribution of U.S. physicians—the invisible driver of health care costs. N Engl J Med . 1993;;328:961-963.
69 +
Nurse Practitioners, Physicians' Assistants, and Certified Nurse Midwives: Policy Analysis . Washington, DC: Office of Technology Assessment; 1986;.
70 +
Freund C.  Research in support of nurse practitioners.  In: Mezey M, McGivern D, eds. Nurses and Nurse Practitioners: The Evolution to Advanced Practice . New York, NY: Springer Publishing Co Inc; 1993;.
71 +
Kavesh W.  Physician and nurse-practitioner relationships.  In: Mezey M, McGivern D, eds. Nurses and Nurse Practitioners: The Evolution to Advanced Practice . New York, NY: Springer Publishing Co Inc; 1993;.
72 +
Pear R.  Health insurance percentage is lowest in four Sun Belt states. New York Times . (October 6) , 1994;:A16.
73 +
Lewis DE.  Coping without coverage. Boston Globe . (May 5) , 1993;:45.
74 +
Lewis DE.  Union oks Boston gas accord. Boston Globe . (May 21) , 1993;:53.
75 +
Seitz R.  The political tea leaves point to medical networks. New York Times . (December 20) , 1992;:D10.
76 +
Pasternak J.  In-house doctors give some firms a health care remedy. Los Angeles Times . (July 11) , 1993;:A1.
77 +
Emanuel EJ, Brett AS.  Managed competition and the patient-physician relationship. N Engl J Med . 1993;;329:879-882.
78 +
Travis MR, Russell G, Cronin S.  Determinants of voluntary disenrollment. J Health Care Marketing . 1989;;9:75-76.
79 +
Hennelly VD, Boxerman SB.  Out-of-plan use and disenrollment: outgrowths of dissatisfaction with a prepaid group plan. Med Care . 1983;;21:348-359.
80 +
Sorenson AA, Wersinger RP.  Factors influencing disenrollment from an HMO. Med Care . 1981;; 19:766-773.
81 +
Clement DG, Retchin SM, Brown RS, Stegall MH.  Access and outcomes of elderly patients enrolled in managed care. JAMA . 1994;;271:1487-1492.
82 +
Henneberger M.  Managed care changing practice of psychotherapy. New York Times . (October 9) , 1994;:A1, A50.
83 +
Salem-Schatz S, Moore G, Rucker M, Pearson SD.  The case for case-mix adjustment in practice profiling: when good apples look bad. JAMA . 1994;; 272:871-874.
84 +
McNeil BJ, Pederson SH, Gatsonis C.  Current issues in profiling quality of care. Inquiry . 1992;; 29:298-307.
85 +
Green J, Passman LJ, Wintfield N.  Analyzing hospital mortality: the consequences of diversity in patient mix. JAMA . 1991;;265:1849-1853.
86 +
Burke M.  HCFA's Medicare mortality data: the controversy continues. Hospitals . 1992;:118,120,122.
87 +
Greenfield S, Aronow HU, Elashoff RM, Wantanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease. JAMA . 1988;;260:2253-2255.
88 +
Robinson ML.  Limitations of mortality data confirmed: studies. Hospitals . 1988;;62:23-24.
89 +
Baker LC, Cantor JC.  Physician satisfaction under managed care. Health Aff (Millwood) . 1993;; 12( (suppl) ):258-270.
90 +
Jelllinek MS, Nurcombe B.  Two wrongs don't make a right: managed care, mental health, and the marketplace. JAMA . 1993;;270:1737-1739.
91 +
Knox RA, Stein C.  HMO doctors want boss out in dispute on patient load. Boston Globe . (November 21) , 1991;:1, 27.
92 +
Freidson E.  Prepaid group practice and the new 'demanding patients.' Milbank Mem Fund Q . 1973;;51:473-488.
93 +
Schroeder JL, Clarke JT, Webster JR.  Prepaid entitlements: a new challenge for physician-patient relationships. JAMA . 1985;;254:3080-3082.
94 +
Brett AS.  The case against persuasive advertising by health maintenance organizations. N Engl J Med . 1992;;326:1253-1257.

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To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
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Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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