The independent physician groups and hospitals provide services under the organization's guidelines, but they may also care for patients who are not members. (1997) While managed care does offer employers more control in choosing the specifics of the health care plan provision at the same time the insurance companies and the profit-drive health-care organizations possess a strong role. Opponents of the government having a primary role in health care financing state that managed care "raises the specter of rationing, lower quality, less freedom to choose physicians, interference with physicians' clinical autonomy, reduced access to specialty care and teaching hospitals, and increased government regulation." (Gottlieb and Einhorn, 1997) Further criticism has been stated in relation to the financial mechanisms employed by managed-care plans geared toward efficiency due to the risk of providers relating to penalties or rewards based on some measures of efficiency.

While health care providers are expected "to provide a wide range of services, recommend the best treatments, and improve the patient's quality of life. However, to keep costs down, they must limit the use of diagnostic services and specialty care, increase efficiency, and shorten the time spent with each patient." (Gottlieb and Einhorn, 1997) According to the American Medical Association there are ethical implications relating to the managed care financial arrangements. Also stated to be fundamental issues in this debate is the fact that "...academic medical centers do not fit naturally within managed-care systems because their missions are so different from those of largely service-oriented managed-care institutions." (Gottlieb and Einhorn, 1997) in fact, the expenses associated with maintaining research and education quality has resulted in many academic medical centers selling the hospital segment of their business.

LITERATURE REVIEW

The David and Lucille Packard Foundation journal 'The Future of Children' Vol. 8, No. 2 states that managed care has "...revolutionized the health care system in America." (1998) Managed care is described as a "vast array of financing and health care delivery practices that are designed to limit costs and ration care." (David and Lucille Packard Foundation, 1998) it is additionally related that healthcare providers and insurers have "created cost0conscious health insurance plans and employers and individuals are subscribing to them at unprecedented rates." (Ibid, 1998) Characteristics common to managed health care plans are inclusive of those as follows:

1) Strong financial incentives for members to obtain health care from only selected providers and hospitals that follow the rules established by the plan.

2) Reliance on gatekeepers, preauthorization, and other techniques to control access to specialty care, diagnostic tests, and hospitalization.

3) Shared financial risk among doctors, the health plan, and other health care professionals through the use of capitated payment methods or bonuses and penalties. (David and Lucille Packard Foundation, 1998)

According to this study reported in 1998, managed care has the potential of improving "delivery, quality and financing of health care services..." (Ibid) Additionally provider networks have served to improve both access to and coordination of care and in addition "the use of financial incentives to providers and members may promote preventive health care." (Ibid, 1998) the information systems which are very sophisticated have the potential to bring about improvement to accountability to customers through costs and services being monitored as well as the health of the managed care system members. Managed care has served to:

1) Reduce overall health care costs;

2) Stimulate the growth of for-profit health care;

3) Stimulate the growth of 'for-profit' health care;

4) Improve the access to preventive health and specifically for children who are privately insured;

5) Decrease access to preventive health care for children enrolled in Medicaid; and 6) Reduce access to specialty care for all insured children with an illness that is 'chronic or disabling'. (Ibid, 1998) critical feature of the revolutionary managed care system is the opportunity that presents in the creation of a managed care system that 'works for children'. The features of such a system are stated as follows:

1) a "medical home" that provides accessible, continuous, comprehensive, family-centered, coordinated, and compassionate care for all children.

2) a defined benefit package that is crafted around children's changing physical and emotional needs.

3) Access to appropriate pediatric specialists for children with chronic or disabling illnesses.

4) Coordinated care both within the managed care network and among other child-serving organizations outside the plan.

5) Rewards and encouragement for the active participation of parents.

6) Fair reimbursement rates, particularly...

(Ibid, 1998)
The work of Seymour H. Levitt (2000) entitled: "Impact of Managed Care on Scholarly Activity and Patient Care: Case Study of 12 Academic Radiology and Radiation Oncology Departments" published in the Journal of Radiology reports a study in which "Six departments of radiology and six departments of radiation oncology from areas with low, medium, or high managed care penetration were asked to complete a questionnaire designed to address the impact of managed care on research and scholarly activity. Information, when available, was taken from fiscal years 1993 and 1998." According to Levitt site visits were made to the 12 departments which were then followed up with questionnaires. Findings of the study show that the departments that had "medium to high managed care penetration" had reported a higher level of dissatisfaction "in their ability to remain active in their education and research goals." (2000)

The results of this study indicate "...that for the period surveyed, the departments needed to increase clinical time to make up for decreasing patient care revenues. In turn, this has reduced the time and money devoted to scholarly activities. Information from this study will be used to develop a trends database for all U.S. radiology and radiation oncology departments. This, together with a more comprehensive study by the RSNA, will assist in measuring the current and potential long-term impact of managed care and other system changes on the practice of radiology and radiation oncology." (Levitt, 2000)

Levitt states that in the current focus held in health care on the marketing and economics of health care that the discussion surrounding health care is quickly becoming "one solely of dollars, policy, budgets and marketing strategies." (2000) This puts the primary purpose and mission of medical care, which is providing care to ill people at risk and diminishes this central purpose. According to Levitt (2000), health care professionals are "being challenged to clearly and strongly define" precisely who they are and what they do in order to "prevent this erosion of the central purpose" of the mission of those in the health care profession as they go about shaping the profession's future in the health care environment characterized by "rapid changes." (Levitt, 2000)

The health care professional's primary responsibility is to its patients and in order to make provision of the "best technology and clinical experience" to patients it is necessary that the health care professional of today "support and participate in scholarly activities" that serve to best inform the health care profession of the best methods of caring for their patients. The following figure is stated by Levitt to illustrate the relation of quality patient care to organizations that sponsor educational and research activities.

Relation of Quality Care to Organizations that Sponsor Educational and Research Activities

Source: Levitt (2000)

Levitt reports that centers of education and research and academic health centers are "under threat from the combined dominance of managed care and legislation results from the 1997 Balanced Budget Act. The revenue that is received from patient care that has been provided at academic health centers and that has been derived from research has been historically utilized in supporting academic health center activities which includes education in basic and clinical science and this revenue is stated by Levitt (2000) to contribute "up to 90% of the budget" however, "with the current focus on cost and budgets, serious problems are occurring within these institutions that are regulating research and education to secondary status..." This has resulted in health care that is high quality in nature being threatened.

In the absence of a strong focus on research and development towards testing new technology and pharmaceutical benefits and risks future health care quality is at risk. Undermining the current and future skill and problem-solving abilities of physicians is the lack of a strong commitment to education. Because previous studies which have cited the adverse effect of managed care on scholarly pursuits have been for the most part merely "anecdotal" the RSNA developed a "two phase project to systematically and scientifically examine the impact of managed care on the scholarly activities of departments of radiology and radiation oncology in the United States." (Levitt, 2000)

Levitt states that the goals of the questionnaires in this study were to "...establish a trends database for all radiology and radiation oncology academic departments nationwide. The database will help departments measure the ongoing impact of managed care and other health care system changes on research and scholarly activity." (Levitt, 2000) Findings of the study state that the majority of the departments, "regardless of managed care penetration recognized the extent of managed care penetration in…