Effective communications with patients is the subject of a vast amount of literature and the focus of skills training for physicians and other practitioners. One set of challenges in patient communication relates to issues brought about by the emergence of managed care. In this brief essay we cite some concerns and suggested strategies. We also offer readings on this topic.

There are a number of ways in which managed care can complicate or even threaten the patient-physician relationship. The following are sources of potential problems and tensions.

• The patient has to select a new primary care physician (PCP) when changing health plans, despite being satisfied with the current physician. The patient may resent the new physician for this reason alone.

• The patient does not understand or comply with the procedures of the health plan for accessing, receiving, and paying for care.

• The patient wants to continue seeing a specialist with whom he has a relationship, but the specialist does not participate in the health plan.

• The patient wants and expects certain services (tests, referrals, treatments) that require a referral, and the PCP or specialist does not perceive a need.

• The patient suspects that the physician has financial incentives to withhold care and therefore decisions are being made based on cost rather than quality considerations. This issue poses the greatest threat to the fundamental trust that needs to exist between patient and clinician.

Experts and the authors of the articles listed below recommend these strategies and approaches.

• As a guiding principle, physicians should always practice ethically and make decisions or recommendations that they believe to be correct. They should not allow financial factors or health plan requirements to sway them from the proper course of care. They should remain patient advocates.

• Secure in the knowledge that he or she is acting properly, the physician must then address the patient's concerns by using communication skills that apply to most difficult situations: empathize with the patient, affirm the commitment to the patient's best interests, explain the decision or recommendation, and listen carefully.

• The clinician should offer options. If the patient prefers to see a non-participating specialist, or to continue with a non-formulary prescription, or to receive a non-covered treatment, the physician should explain the trade-offs, including the patient's having to pay more out-of-pocket.

• If the patient persists in requesting a test or referral that the physician feels is not warranted, the physician can ease the situation by suggesting that the test or referral can take place later, if the recommended initial course of action does not resolve the diagnosis or adequately treat the condition.

• The practitioner should educate patients about health plan policies and procedures. This can be done proactively with an information sheet, and also as needed at the time of referrals, prescriptions, or other care decisions.

• Experts advise physicians to refrain from criticizing or blaming the health plan, i.e., the "common enemy" approach. This distracts the patient and physician from the decisions they need to make, now and in the future. It can also make the patient feel uncomfortable about having chosen to enroll in the health plan.

• If the patient is concerned that financial incentives are influencing the physician's decisions, then the physician should discuss the matter openly. It may be difficult to explain complicated reimbursement arrangements, but the key message should be that payment does not compromise quality. The consensus opinion seems to be that physicians need not discuss reimbursement as a routine matter. Kao et al (2001) found that only about half of the patients surveyed wanted to be informed about their physician's payment method. However, in the same survey, a majority of patients believed that using a bonus or withhold designed to limit use of services would have a negative impact on quality of their care. So physicians need to be alert to this issue.

Beyond the dialogue that occurs during the patient visit, there are ways that the health care system can help practitioners maintain positive patient relationships.

• Educational programs should provide communication skills training to help clinicians deal with these specific managed care situations, just as they address difficult topics such as end-of-life or sexual preference.

• Health plans and delivery system that set policies and procedures that affect patients should assume responsibility for informing their members about these rules so that clinicians do not have to do it by themselves. Also, the rules should grant some flexibility and allow exceptions under certain circumstances to policies governing referrals or other services so that the physician can present options when he or she feels that deviations from standard procedures are justified.

• Bartlett, E. How to say no to a managed care patient. Medical Economics. September 8, 1997;74(18):65-70.

• Kao A, Zaslavsky A, et al. Physician incentives and disclosure of payment methods to patients. J Gen Intern Med. March 2001;16(3):181-188.

• Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship: tools for improving communication in managed care. JAMA. October 20, 1999;282(15):1477-1483.

• Levinson W. In context: physician-patient communication and managed care. Journal of Medical Practice Management. March/April 1999;14(5):226-230.www.mpmnetwork.com/article.cfm?id=45

• Levinson W. Paid not to refer? J Gen Intern Med. March 2001;16(3):209-10.

• Lowes R. Explaining things to an angry managed care patient. Medical Economics. April 14, 1997;74(8):143-156.

• Ubel P. Money talks, patients walk? J Gen Intern Med. March 2001;16(3):204-205.

• Walker L. Talking to patients about managed care. Hippocrates. November 1999; 13(10):40-44. www.hippocrates.com/archive/November1999/11features/11featmanaged.html