[Physician's anxiety and physician's elegance. Problems in dealing with cost reduction, education of general practitioners and optimal size of practice networks in a cross-national comparison].
The key reason for physicians networking in managed care is to get a better coping with uncertainty on action (treatment) decisions. The second reason for networking in managed care are financial benefits grounds. But this reason is very ambivalent. Three different action problems (role conflicts) in managed care network are to solved, which was also in single practices. In the lecture the decision strategies and decision resources has been compared. Observations are done using expert interviews, patient interviews and analysis of documents in USA, Germany and Switzerland. The first problem is the choosing of a cost reduction strategy which is not reducing the effectiveness. Such "ugly" solution strategies like exclusion of "expensive" patients and a rationing of necessary medical services in a kind of McDonalds network of physicians will fail the target. The optimost way is a saving of all unnecessary medical even injourious performances. The chosen cost reduction strategy is not real visible from outside but in fact limited cognizable and controllable. Evidence based health care can be a resource of treatment decisions and could train such decisions but it will not substitute these decisions. The second problem is the making of real family practitioners as gatekeepers. Knowledge about the care system is still not making a real family practitioner, even if this is the minimum condition of their work. Also contractual relationships between insurance and doctor as a gatekeeper or financial incentives for patients are still making not a real family practitioner as a gatekpeeper. Only throughout the trust of patients supported by second opinions is making the real family practitioner as a gatekeeper. "Doctor hopping" could be the reaction by scarcity of trustworthy family practitioners as gatekeepers. The third problem is the choosing of the optimal scale of a network due to the very different optimal size of networks regarding the requirement of risk spreeds, of the motivated engagement, of competition, incentives of inclusion of insurantes, they always need other net sizes. But it is possible, for each requirement there could function different networks. A practice (doctor's office) can be a member in different networks in several levels. The social transition from a small office to a network of offices is in all business lines a cultural shock involving not only benefits also psychical and social distress. In this there is no difference between health or agriculture or each other business of trade and industry. The destiny of the joint doctor's offices in Germany suggest due to a very serious power to scatter this networks. The comparative analysis of conflicts, strains, resources and strategies of associations and networks could yield from a developed methodical repository in sociology and social psychology what exists since 40 years (see also Meyer--in this journal). But therefore must be included also the action problems, which are only mentioned in passing of the according profession horizon.
Behrens
J
J
Medizinische Fakultät, Institut für Gesundheits- und Pflegewissenschaft, Martin-Luther-Universität Halle-Wittenberg.
D003363:Cost Control / Q000639:trends; D003431:Cross-Cultural Comparison; D005194:Family Practice / Q000191:economics* / Q000193:education; D005544:Forecasting; D020793:Gatekeeping / Q000191:economics*; D005858:Germany; D006801:Humans; D008329:Managed Care Programs / Q000191:economics*; D009313:National Health Programs / Q000191:economics*; D010819:Physician's Role; D010818:Practice Patterns, Physicians' / Q000191:economics