The advent of managed care has affected much in medical practice, not the least of which is the traditional doctor/patient relationship. Not only is there a "third party" whose standards and guidelines must be factored into decisions, but the changes that have developed in the medical market place, have also changed the ways in which patients choose their physicians. Often physicians are no longer selected upon the recommendation of another long-standing, satisfied patient or upon the recommendation of a trusted physician, but from a list provided by the patient's managed care organization. Many patients are forced to leave the practices of physicians who have treated them over many years and are very dissatisfied about having to do so. Some of these changes have the potential to have significant, negative impact upon the physician's ability to develop an effective doctor/patient relationship with his/her patients.

Recognizing the significant correlation between patient relationships and medical liability cases being brought against physicians, we take this opportunity to highlight some of the areas of concern, from the patient relations/quality care perspectives.

Appointment Schedules
Under managed care, physicians must often see many more patients than they used to see in any one session. This often means that patients seeking non-urgent appointments may not be able to make them for many weeks into the future. In some instances this may be acceptable but in order to help ensure that it is, staff should have guidelines which help to prevent inappropriate delays in patients being seen by the physician. For example, the physician may need to review with his/her staff the types of problems that require urgent or emergent care in his/her practice. Staff should also be aware that even though a patient may not have been seen in the practice previously, where his complaints or symptoms warrant, he may have to be given an expedited appointment.

Waiting Time
Also, because of the increased number of patients which many physicians must now see, practices may experience a concomitant increase in waiting time. This is known to be a major complaint by patients against their physicians, therefore, the practice should evaluate whether such a change is occurring and, where possible, make efforts to keep waiting time reasonable.

For example, your evaluation may reveal that the number of patients being scheduled per hour cannot be seen in that time, resulting in increased waits; or you may find that a large number of urgent patients are being accommodated, resulting in delays for patients with previously scheduled appointments. Changes in the number of patients scheduled per hour or leaving some appointment slots to be available for those urgent visits, may help to alleviate the problem.

This is an area in which patients will "evaluate" the practice, particularly if they are new to the practice. Many managed care organizations also query patients regarding waiting time; these findings may be factored into the organizations' evaluations of their participating providers.

Telephone Advice/Treatment
In many practices there are patients who would prefer to get a prescription or other advice or treatment by telephone rather than to come into the office. From the practice's perspective, that option may become more attractive in certain instances, especially where it may help to alleviate the scheduling problem.

As always, great caution must be exercised in making diagnoses and providing treatment and/or advice to patients who have not been seen. Where this is done, the physician must ensure that both the information provided to him by the patient and his response are well documented in the patient's chart; this information maybe important for subsequent care and treatment of the patient. The physician must also be very cautious in delegating the responsibility for phone advice to others in the practice. (Please refer to PRI's Loss Prevention Technique: "Developing Telephone Protocols for the Medical Practice", April - June 1996).

Another area where the primary care physician must be cautious, is where a patient calls requesting a referral and is told that referrals are not provided unless the patient is seen by the primary care physician. The physician must ensure that his staff is knowledgeable in obtaining the appropriate information regarding the patient's problem, so that an informed decision may be made, as to how soon the patient is to be seen.

Telephone Capacity
The increased numbers of patients in many practices may also mean that the number of phone lines are no longer sufficient to handle the number of calls. Telephone capacity should be evaluated, to help ensure that patients are able to contact the practice without inordinate difficulty.

Bearing in mind that many of your new patients may have had to change physicians because of changes in their health plans etc. and that it will take time to build relationships with their new physicians, practices must be aware that all of the areas discussed above can impact upon this relationship. Therefore, these areas must be monitored, evaluated and addressed by the practice as necessary.

Below is a list of our Loss-Prevention Techniques:

Telephone Matters | Patient Relations | Test Results and Follow-up Monitoring Patients | Patient Follow-up
Guidelines for Comprehensive Office Chart
Emergency Prepardness | Developing Telephone Protocols
Medical Office Personnel | Medication Matters
Issues in Physician Coverage
Discounting the Doctor/Patient Relationship