title: Managed care, access to specialists, and outcomes among primary care patients with pain.
abstract: OBJECTIVE
  To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain.
  
  
  METHODS
  Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans.
  
  
  METHODS
  A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle.
  
  
  METHODS
  Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines.
  
  
  RESULTS
  A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians.
  
  
  CONCLUSIONS
  Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.
authors.affiliation: Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle 98195-7660, USA.
authors.forename: David E
authors.initials: DE
authors.lastname: Grembowski
authors.forename: Diane
authors.initials: D
authors.lastname: Martin
authors.forename: Paula
authors.initials: P
authors.lastname: Diehr
authors.forename: Donald L
authors.initials: DL
authors.lastname: Patrick
authors.forename: Barbara
authors.initials: B
authors.lastname: Williams
authors.forename: Louise
authors.initials: L
authors.lastname: Novak
authors.forename: Richard
authors.initials: R
authors.lastname: Deyo
authors.forename: Wayne
authors.initials: W
authors.lastname: Katon
authors.forename: Deborah
authors.initials: D
authors.lastname: Dickstein
authors.forename: Ruth
authors.initials: R
authors.lastname: Engelberg
authors.forename: Harold
authors.initials: H
authors.lastname: Goldberg
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008329:Managed Care Programs / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010146:Pain / Q000453:epidemiology; D059408:Pain Management; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data; D015397:Program Evaluation; D011446:Prospective Studies; D012017:Referral and Consultation / Q000458:organization & administration; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology; D014861:Washington / Q000453:epidemiology