A survey by the Center for Studying Health System Change offers insight into how physicians' views of managed care have changed as the payment system has evolved.

A strong emphasis on primary care and tight limitations on specialty care were hallmarks of managed care in the mid-1990s. Now, the data seem to indicate, reduced reliance on the gatekeeper has made specialists a happier group with respect to how much autonomy they have in providing care, and what they're being paid.

"Specialists' sense of increasing clinical autonomy paralleled a rise in their perception that clinical decision making would not affect their incomes," the report states. "Between 1997 and 2001, the proportion of specialists agreeing they could make clinical decisions in the best interest of patients without affecting their bottom lines rose from 68.6 percent to 79.6 percent, while the corresponding proportion of PCPs reporting clinical autonomy again remained almost constant."

Physicians who agree that they have the "freedom to make clinical decisions that meet patients' needs"

SOURCE: HSC COMMUNITY TRACKING STUDY PHYSICIAN SURVEY, CENTER FOR STUDYING HEALTH SYSTEM CHANGE

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