Researchers Study How Managed Care Affects Preventive Advice

Despite assertions that managed care organizations and health maintenance organizations are concerned about disease prevention and health promotion, they rarely give patients the advice they need to modify risky behaviors. And a chief reason may be because many managed care plans do not ensure continuity of care -- "a regular doctor" -- to foster the patient-physician relationship. Consequently, physicians may be less likely to give important advice for prevention.

These findings are in the article "Prevalence and Correlates of Physician Advice for Prevention: Impact of Type of Insurance and Regular Source of Care" in the fall issue of the Journal of Health Care Finance. Dr. Daniel Gentry, assistant professor of health administration, and Dr. Daniel R. Longo, professor of family and community medicine at the University of Missouri-Columbia School of Medicine, and colleagues wrote the article.

Researchers studied 3,024 adults 18 years of age and older living in 12 counties in Southeast Missouri. The subjects live in rural areas that are medically underserved, have high rates of cardiovascular disease (CVD), have low education and income levels, and live where residents engage in risky health behaviors.

Prevention has been identified by health policy makers, researchers and practitioners as a means not only to improve health, but also to control expenditures in managed care. Gentry's study examined the prevalence of physician advice for four preventive health behaviors for cardiovascular disease: increasing physical activity, eating more fruits and vegetables, stopping smoking and losing weight.

Gentry found that respondents with a regular source of care were twice as likely as others to report physician advice in all four preventive health areas. "Our findings provide further evidence that individuals who see their own physician on a regular basis may receive better care. Enduring relationships, leading to greater knowledge of patient history and more open communication, may provide an atmosphere in which physicians are more likely to counsel and advise," Gentry said.

Managed care plays a part in the likelihood of patients having a regular doctor. "Getting good health care has always been about issues of access," Gentry said, "which used to mean having insurance or being able to pay out of pocket. But now, as managed care increases its penetration in the marketplace, even those with good health insurance are not assured of seeing the same doctor each visit or having unimpeded access to a doctor."

Ninety-seven percent of physicians believe that it is their responsibility to give advice to modify patient behavior to reduce risk factors. Despite this belief, the provision of preventive services by physicians is relatively rare. Less than half of the study respondents reported any physician advice about prevention.

Who most often receives a doctor's advice? Middle aged and older adults were more likely to receive physician advice than younger adults ages 18 to 34 or elderly adults age 75 and up. This concerns Gentry and his team. "It points to the possibility of missed prevention opportunities among young adults and misperceptions about the impact of prevention on quality of life among the elderly," Gentry said.

If a behavioral risk factor is immediately visible to the physician, he or she is more likely to ask the patient questions and give advice. Physician advice to stop smoking and lose weight were twice as prevalent as advice to eat more fruits and vegetables and to increase exercise. Unlike smoking and obesity, which are usually apparent to the observer, poor nutrition and lack of exercise are not. "This has important implications for medical and other clinician education and training programs, with regard to increasing awareness among primary care physicians," Gentry said. "Doctors need to ask about behaviors that are less obvious. When asked, patients will reveal risk behaviors, even ones that tend be difficult to disclose --such as those for HIV, alcohol abuse, tobacco use and domestic violence."

But if doctors don't ask, it's unlikely the patient will volunteer the information. Studies have shown that when doctors do give advice about how to improve their patients' health, patients do listen. "It's essential that health providers initiate these conversations," Gentry said. "Managed care needs to realize the importance of having a regular doctor. Consistent providers strengthen the doctor/patient relationship and help the patient be more comfortable talking about their behaviors."

This is one of several studies funded by the Prevention Research Center at Saint Louis University, one of the 23 centers in the Prevention Center National Network authorized by the Centers for Disease Control and Prevention. Dr. Ross Brownson, professor of epidemiology and chair of the department of community health, another co-author of the study, is director of the Saint Louis University Prevention Research Center. Robyn A. Housemann is project manager and also a co-author of the study.

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