We ain't where we wanna be,

We ain't where we oughta be,

We ain't where we gonna be,

But we sure ain't where we was.

SOJOURNER TRUTH

The U.S. health care system is undergoing a major revolution, that is, the corporatization and mass integration of health care. These changes, also known as managed care, are having dramatic effects on specialty practice. In the past, specialist physicians practiced relatively independently and allocated health care resources without oversight or market consideration. Specialists now are likely to practice in a managed environment, resulting in discounted fees, some type of professional supervision, and a referral base that has tightly controlled utilization guidelines.

The trend toward consolidation and integration appears irreversible, at least in the short run, and encompasses all spheres of health care, including hospitals, insurance plans, purchasers, and providers. <sup>8 Kutner R. Columbia/HCA and the resurgence of the for-profit hospital business N Engl J Med 1996 ;  335 : 362

Cliccare qui per andare alla sezione Riferimenti</sup> It is quite likely, given the current trends, that most, if not all, specialists will find themselves involved in some type of integrated delivery system for a significant portion of their practice. In some specialties that are currently overpopulated, such as gastroenterology, the integration trend will be accelerated because these specialists are more susceptible to market pressures. <sup>10 Meyer G.S., Jacoby I. , e al. Gastroenterology workforce modeling JAMA 1996 ;  276 : 689

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Since the collapse of President Clinton's proposed national health plan, there has been no national standard or model for consistency in integrated delivery systems. Instead, each metropolitan area is developing its own brand of managed care and its own unique style of integrating providers, based on local or state legislation, local economic and employment factors, the power of academic institutions, and the vagaries of local health care organization.

Regional managed care environments vary dramatically. In some places, such as Minnesota, it is illegal to operate as a for-profit health maintenance organization (HMO), and thus national for-profit HMO companies have no presence. The Minneapolis–St. Paul area has a disproportionate number of Fortune 500 corporations that self-insure under Employee Retirement Insurance and Security Act (ERISA) regulations. Because ERISA forbids capitation, the dominant mode of payment that has evolved is discounted fee for service. <sup>1 Baumgarten A.   Minnesota Managed Care Review : Minneapolis (1995). 

Cliccare qui per andare alla sezione Riferimenti</sup> The area also has an active business coalition that has a great impact on local health care organization. In contrast, in California, it is illegal for nonphysicians to own physician practices; thus provider-managed independent practice associations (IPAs) with capitated payment structures have evolved. Some areas, such as Marshfield, Wisconsin, and Rochester, Minnesota, are dominated by large multispecialty physician group practices. In places such as Mississippi, the managed care penetration remains quite low.

This bewildering array of integrated delivery systems with different levels of penetration, varying from state to state and even different locations within states, has made it difficult for specialists to compare and extrapolate experiences. This situation has left specialty physicians feeling confused and uncertain as to the proper integration strategies to pursue and has made it difficult for specialty societies to act cohesively.

Perhaps the most ominous managed care development for specialists is the loss of autonomy of their primary care referral base. In multiple locations, such as Toledo, Ohio, Ogden, Utah, and Minneapolis, more than 75% of the primary care practices have been purchased by hospital corporations, health plans, or national physician practice management companies. <sup>5 Holowerko M. Is this the end of the line for independent practice? Medical Economics March 10, 1997 ; 58-79

Cliccare qui per andare alla sezione Riferimenti</sup> Whatever the various reasons for this development, the impact on specialty referral patterns will be great. Referrals will almost certainly become more unpredictable in these locales and could be determined by the caprice of the corporate owners. Specialists in these areas will have to be well organized and involved in the appropriate integrated structures to prevent a loss of patient base.