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MPC 97-011 – HSR&D Study

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MPC 97-011
Negotiating Patient Expectations and Requests in a Managed Care Environment
James A Tulsky MD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: April 1998 - March 2001

BACKGROUND/RATIONALE:
Intense pressures to contain health care costs have stimulated rapid growth of the managed care industry. Managed care organizations contain costs a number of ways, including drug formulary restrictions, limitations on the number of specialists, and pre-authorization requirements for certain services. This raises the possibility that veterans seeking care at VAMCs will encounter new barriers to receiving services they desire. In an era of managed care and cost constraints it is crucial to understand how patients and physicians deal with resource limitations.

OBJECTIVE(S):
The project has the following specific objectives: 1) to describe the nature and prevalence of patients' expectations and requests for diagnostic tests, referrals, and new drug prescriptions in the VA outpatient, primary care setting; 2) to determine the relationship between patient demographic factors, unmet expectations and unfulfilled requests, and patient satisfaction; 3) to describe the range of reasons primary care providers cite for not meeting patient’s expectations and fulfilling requests for diagnostic tests, referrals, or new drug prescriptions; 4) to characterize the negotiations between providers and patients about expectations and requests for diagnostic tests, referrals, or new drug prescriptions; 5) to describe the relationship between provider communication style, percentage of unmet expectations and unfulfilled requests, and patient satisfaction; and 6) to identify communication strategies that maximize patient satisfaction when providers deny patients' requests for diagnostic tests, referrals, and treatments.

METHODS:
We used a two-phase study design to meet these objectives. In Phase I, we surveyed VA outpatients before they visited their primary care providers. We identified their expectations and planned requests for services during the visit. After the visits, we surveyed them again to learn whether their expectations were met and their requests were fulfilled, and the extent to which they were satisfied with their care. In Phase II we used data from Phase I to identify patients at high risk of having unmet expectations. We audiotaped patients’ visits with the provider and gathered post-visit information from patients and providers.

FINDINGS/RESULTS:
While piloting our project, we examined the relationship between the type of instrument used to measure patients’ expectations and patient satisfaction. Our results suggest that the type of instrument used to measure patient expectations does, in fact, affect key outcome variables. A questionnaire with more expectations to choose from generates more expectations than a questionnaire with fewer expectations. Different measurement instruments, however, do not affect patient satisfaction. Preliminary analyses of Phase I data suggest that patients’ expectations are heterogeneous and expectation status does not affect patient satisfaction.

IMPACT:
The data emerging from this study will help VA health care providers better negotiate patients’ expectations and desires in these changing times. Successfully negotiating these expectations will help providers respond to the needs of veterans and ensure the competitiveness of the VA health care system in the larger health care marketplace.

PUBLICATIONS:

Journal Articles

  1. Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Jeffreys AS, Grambow SC, Tulsky JA. Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction? Journal of general internal medicine. 2004 Nov 1; 19(11):1080-7.
  2. Abbott KH, Sago JG, Breen CM, Abernethy AP, Tulsky JA. Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support. Critical care medicine. 2001 Jan 1; 29(1):197-201.
  3. Peck BM, Asch DA, Goold SD, Roter DL, Ubel PA, McIntyre LM, Abbott KH, Hoff JA, Koropchak CM, Tulsky JA. Measuring patient expectations: does the instrument affect satisfaction or expectations? Medical care. 2001 Jan 1; 39(1):100-8.
Conference Presentations

  1. Tulsky JA, Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Shearin AL, Grambow SC, Koropchak CM. The nature and prevalence of patient expectation in a VA general medicine clinic. Paper presented at: Society of General Internal Medicine Annual Meeting; 2000 May 1; Boston, MA.
  2. Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Shearin AL, Grambow SC, Koropchak CM, Tulsky JA. The nature and prevalence of patient expectations in a VA general medicine clinic. Paper presented at: VA HSR&D National Meeting; 2000 Mar 23; Washington, DC.
  3. Peck B, Asch DA, Goold SD, Rotor D, Ubel P, Tulsky J. Measuring patient expectations: Does the measurement instrument affect the number of expectations elicited and patient satisfaction. Paper presented at: VA HSR&D National Meeting; 1999 Feb 1; Washington, DC.


DRA: Health Systems
DRE: none
Keywords: Communication -- doctor-patient, Managed care, Patient preferences
MeSH Terms: Managed Care Programs, Patient Satisfaction, Patient-Centered Care

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