The shift toward a managed care environment in a multispecialty group practice model. Looking for reciprocal benefits.

Managed care is notably affecting the practice of surgery in the United States. Four principal elements are subject to change: (1) patient care patterns, (2) ethics, (3) education and research, and (4) surgeon compensation. The Virginia Mason Clinic, a multispecialty group practice, is adapting to the demands of managed and capitated care. With the patient as the primary focus of effort, the goal is to create optimum value in health care. The principles of Continuous Quality Improvement are used to increase value in health care by ensuring appropriate treatment with optimum outcome at reasonable cost. Practice patterns are shifting to provide value to patients and payers. Ethical conflicts threaten but have been avoided. Surgical education remains unaffected, but future funding is problematic. The emphasis in surgical research has shifted toward outcome-based studies. The conflict between work effort and resource conservation as determinants of physician compensation is less for surgical than for medical practitioners. Although the principal benefactors of the shift toward managed care have been the payers, patients have gained modestly through efficiencies in the health care process and more stable insurance premiums. The satisfaction level of the surgeons in our multispecialty group practice remains high. Surgical research is thriving, volumes and case mix remain excellent, and changes in practice pattern have enabled us to increase efficiency without compromising patient care.