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The Media vs Managed Health Care
Are We Seeing a Full Court Press?
David B. Bernard, MD;
David J. Shulkin, MD
Arch Intern Med. 1998;158:2109-2111.
ABSTRACT
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Background Despite the fact that medical coverage for many Americans is shifting rapidly from traditional insurance to managed care, studies suggest that most citizens have limited knowledge or understanding of the implication of this change.
Objective To evaluate the predominant message being portrayed by the lay press on managed care.
Methods We conducted a review of newspaper articles dealing with managed care from several leading national newspapers. Surveys, editorials, letters to the editor, or nonclinical articles were excluded. The articles were examined to evaluate their likely effect on the reader's willingness to join a managed care organization, and were scored using a standardized survey instrument. The final analysis included data from 85 articles from an original pool of 277.
Results In only 8% of cases, the articles were considered likely to have had a positive influence on the reader and, thus, encourage them to join or remain with a managed care organization. More important, in fully two thirds of cases, we believed the articles portrayed so unfavorable a message that the reader was less likely to join, or might even decide to leave, a managed care organization. The articles dealt most frequently (67%) with patient concerns with managed care, focused mainly on cost and quality issues, and managed care representatives were the people whose opinions were most commonly (53%) solicited.
Conclusions It seems highly likely that public perception of managed health care will be influenced by the strongly negative representation being portrayed by the newspapers. While debate over the good vs bad features of managed care continues, available evidence suggests this form of health care coverage continues to grow. The press is likely to remain an important source by which information about managed care is transmitted to the public and will certainly influence public decision making on the issue. If the current negative representation continues, we may soon begin to see a widespread backlash of public opinion opposing this form of health care.
INTRODUCTION
AMERICANS are grappling with the impact of a rapidly changing health care marketplace, in particular the increasing shift of medical coverage from traditional insurance to managed care. Yet the majority of the public admit their lack of understanding of managed care.1 Public perception of managed care is shaped by many factors, including the media's portrayal of these matters.2
So what have Americans been reading about managed care? Recently there has been a flurry of high-profile news items documenting anecdotal horror stories of patient encounters with managed care, gag-rule controversies involving the physician-patient relationship, and exposés of large corporate profit margins and executive salaries in the managed care industry. Are these widely quoted articles a skewed sample of media reports about managed care or has recent media coverage truly been projecting a negative image of the industry? We sought to determine the nature of the media's coverage of managed care by examining the content of articles in several of the country's leading newspapers. The objective of this article was to evaluate the predominant message by the lay press concerning managed care.
METHODS
Newspaper articles involving managed care were electronically selected using the Lexus/Nexus database. Articles were identified using the key phrase "managed care" in conjunction with the following terms: "health maintenance organizations, physicians, or patients." We confined our review to all articles from the last quarter of 1995 (October 1-December 31 published in several of the nation's leading newspapers. Specifically, the newspapers included in this study were New York Times , Los Angeles Times , Chicago Tribune, Philadelphia Inquirer, Washington Post , and Boston Globe.
Newspaper articles were reviewed in detail and were included in the study if they related predominantly to discussions of clinical quality, cost of care, resource utilization, or satisfaction with managed care. We excluded those that were editorials, letters to the editors, or did not discuss clinical issues related to managed care (such as descriptions limited to enrollment trends).
The full text of all study articles was reviewed independently by a 5-member review committee. Members of the committee were board-certified physicians affiliated with the University of Pennsylvania Health System's Fellowship Program in Managed Care and Quality Management in Philadelphia. All reviewers had at least 10 years of clinical practice, represented physicians with practice both in community and academic practice settings, and were from a varied distribution of clinical disciplines (a general internist, a family practitioner, a pediatrician, a nephrologist, and an anesthesiologist). Reviewers were asked to independently score each newspaper article using a standardized survey instrument. In scoring each survey question, the majority opinion of the reviewers was used to determine the overall group opinion.
Reviewers were asked to indicate whether an individual, after reading the article, would be (1) more likely to join (or stay with), (2) be less likely to join (or possibly leave), or (3) have little or no effect on their willingness to join or leave a managed care organization. Reviewers were also asked to characterize the predominant perspective from which the article was written (patients, physicians, hospitals, employers, or a combination of these), as well as the primary focus of the article's content (clinical quality, financial issues, insurance coverage, patient satisfaction, or resource utilization). Reviewers also recorded whose views were solicited in the articles, if any, including patients, physicians, hospital administrators, managed care representatives, employers, or other individuals or groups. In all, 8 specific issues about managed care from each article were sought and the results were graded according to a standard Likert scale methodology.
RESULTS
From the targeted newspapers we identified a total of 277 articles involving managed care. Using the exclusion criteria, 192 articles were removed from the study group, leaving 85 articles for analysis.
Results of the reviewers' perception of the articles' representation of managed care are as follows:
Of 85 total articles, 7 articles (8%) were thought to likely influence readers so that they would be willing to join (or stay with) a managed care organization. In 57 articles (67% of the total), the reviewers believed that the articles' representation of managed care was unfavorable and might lead the reader to be less likely to join, or possibly decide to leave, a managed care organization. Twenty-five percent of articles were considered to likely have little or no effect on the willingness of the reader to join or leave a managed care organization.
The newspaper articles focused most of their content on patient concerns with managed care. In approximately two thirds of articles, the article content dealt with patient perspectives of managed care organizations.
There was also frequent discussion of the adequacy of insurance coverage with managed care (38%), and physician concerns with managed care organizations (28%). Most articles concentrated on issues involving clinical quality (58%) and the cost of care in managed care settings (56%). Satisfaction with managed care organizations was a primary issue in approximately one quarter of articles reviewed.
The media solicited views from a wide audience (Table 1 and Table 2). Newspaper reporters were most likely to include comments from managed care organization representatives in their articles (Table 1). Views from physicians and patients were also frequently included. Patient advocacy and consumer groups, politicians, and lawyers were more likely to be interviewed than hospital administrators or employer groups. In 9% of cases, the articles failed to quote any external perspective.
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Table 1. Individuals Whose Views Were Solicited*
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Table 2. Other Individuals Interviewed for the Media Articles
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COMMENT
Approximately two thirds of articles from leading US newspapers surveyed as part of this study provided a negative representation of managed care. Much of this reflects reporting of hostile, unfavorable encounters of patients with managed care organizations, frequently around denied services perceived as necessary by the patient. It seems highly likely that public perception of managed care will be influenced by this coverage. Although managed care enrollment continues to grow across the country, apparently not yet affected by a negative press image,3 our findings suggest we may soon begin to see a backlash of concern. Indeed, the increasing number of lawsuits against managed care companies suggests that it is already happening.
In most articles we reviewed, editorial content was focused largely on patient concerns with managed care, a fact that may again contribute to a growing public negative perception. Our study is limited by a number of factors, including the fairly short time frame examined, the selective number of newspapers included, and the fact that the reviewers were all members of the medical profession. The intent was to provide a snapshot of managed care reporting from a group of highly prestigious newspapers rather than for it to be an exhaustive review of the topic. Despite such limitations, there was remarkable consistency between the various newspapers. Most articles targeted their content toward quality and cost issues, as they affect patients, and were much less likely to discuss employer concerns about managed care organizations. Clearly, rather than employers or providers, the consumers of health care are receiving the media's attention in the ongoing debate about the changing types of health care coverage.
The precise impact of the media's representation of managed care may be hard to determine. However, one possibly related event is the recent increase in legislative initiatives directed toward managed care. Throughout the country, in 1996 and 1997, more than 1000 antimanaged care bills have been proposed.4 Legislatures have considered mandatory length-of-stay provisions, antigag rules, emergency service denial restrictions, and restrictions for provider incentives for limiting care.
The "bad" press has not gone unnoticed by the managed care industry. Discussions at recent health maintenance association meetings have focused on these perceived attacks on the industry. Industry trade groups have formed committees to develop positive messages for managed care and have proposed public relations campaigns using infomercials and patient testimonials regarding the benefits of managed care.5 Conferences have been offered to industry representatives on how to deal with negative representations of managed care.6 One managed care company, in response to a series of newspaper articles, sent a letter to its members assuring them of the attention they are paying to quality.7
It is difficult to know what influence the media has had on these past series of events in the industry. Our review is of more recent media coverage, so the current impact of the media remains to be evaluated. Up until now, coverage by the press appears to have not adversely affected enrollment in health maintenance organizations. The number of people converting to managed care plans increased by more than 13% from 1994 to 1995.3, 7 Some industry leaders remain generally unconcerned that a media backlash will seriously threaten their aggressive plans in the marketplace.7
The debate over the virtues on the one hand and potential ill-effects of managed care on the other will likely continue for the foreseeable future. Data on enrollee satisfaction with managed care are mixed. Some reports8 suggest a higher level of satisfaction with managed care plans, while others9 suggest that satisfaction is declining. As long as data on clinical outcomes and other quality measures remain sparse, issues of quality in managed care will remain controversial. Yet the types of outcome studies needed to supply reliable data are complex and take a long time to complete. In the meantime, the press will continue to be instrumental in providing the public with all kinds of information about managed care. This information will inevitably play an important role in influencing public decisions about their health care coverage.
AUTHOR INFORMATION
Accepted for publication February 19, 1998.
Corresponding author: David B. Bernard, MD, Hospital of the University of Pennsylvania, One Founders, Administration, 3400 Spruce St, Philadelphia, PA 19104 (e-mail: bernardd{at}mail.med.upenn.edu).
From the Division of General Internal Medicine, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia.
REFERENCES
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1. Wynn P. The public's view of managed care: a fuzzy one. Managed Care. December 1995:9.
2. McCombs M, Shaw D. The agenda setting function of mass media. Public Opinion Q. 1972;36:175-187.
3. Kostreski F. Bad press isn't hurting HMO, PPO enrollment. Internal Medicine News. August 1996:54.
4. Bodenheimer T. The HMO backlash: righteous or reactionary? N Engl J Med. 1996;335:1601-1604.
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5. Azevedo D. Will the states get tough with HMOs? managed-care proposals pile up nationwide. Med Econ. 1996;73:172-189.
6. Managed Care Backlash: Strategies to Overcome Negative Perceptions of Managed Care. Boston, Mass: Managed Care Advisory Council; 1996.
7. Zeigler J. Behind the scenes of the managed care backlash. Business Health. August 1996:26-28.
8. Sisk JE, Gorman SA, Reisinger AL, et al. Evaluation of Medicaid managed care: satisfaction, access, and use. JAMA. 1996;276:50-55.
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9. Jensen J. HMO satisfaction slipping: consumers. Modern Medicine. October 1996:86.
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