Ta KT, Persing JA, Chauncey H, Bradley H, Miller SH. Annals of Plastic Surgery. 48(4): 348-354, April 2002.

Background: Medical education and research are inextricably linked to clinical practice, and vice versa. If clinical services become more privatized, what impact will the market place have on clinical practice, teaching, and research? Managed care is the dominant form of clinical practice in the US. The practice of managed care offers observations and insight into the constraints, contingencies, and threats imposed by a managed care-driven economy. This example focuses on academic plastic surgery.

Objectives:

• To determine if there have been changes in clinical practice, research and teaching in academic plastic surgery in recent years.
• If there have been, are they associated with changes in the managed care environment?

Methods: This is a cross-sectional study examining the effect of managed care on clinical practice, research, and teaching in plastic surgery between 1990 and 1997. Ninety-four plastic surgery programs in the United States were sent a 16-item questionnaire probing a spectrum of questions related to managed care. Ten percent of the data were double-checked for entry errors and consistency. Descriptive analysis, correlations, and linear regression were used to analyze the effects of managed care.

Results: The response rate was 70%. There were substantial impacts associated with managed care on clinical practice, research, and teaching. The proportion of clinical practice increased by 5.3 hours per week, on average. Correspondingly, the percentage of cosmetic surgery increased from 18 to 28.3% of plastic surgery practice, with a proportional reduction in reconstructive surgery. As for research, there was a mean reduction of 2.8 hours per week, with a reduction between 1990 and 1997 from 9% to 5% of faculty time. Although there was a decrease in teaching, it was not statistically significant.

Limitations: The data offered by program directors were not independently verified and provided estimates of workload or activities performed, as opposed to actual measured or observed values. Causal relationships between managed care and practice/teaching/research cannot be established by this study.

Conclusion: Managed care increased the time spent in clinical practice of plastic surgery, emphasizing cosmetic as opposed to reconstructive surgery. Research decreased significantly and while teaching was also reduced, the reduction was not statistically significant for the period under study.

Relevance: The public/private nature of the health care system influences clinical practice, research, and teaching. The economic incentives within privately delivered managed care augment and intensify clinical practice, whilst reducing activities in research and teaching. Economic incentives inherent in privately delivered and privately funded managed care affect the kinds of care delivered, focusing on more lucrative procedures (cosmetic surgery) rather than on less lucrative procedures (reconstructive surgery). These findings have been seen elsewhere and point to how the incentives arising from managed care influence the role and actions of physicians. Moreover, it offers insight to training programs, institutions and colleges that the structure, funding, and delivery of health care materially impact academic activity.