Abstract:

Managed care organizations may use payment incentive strategies to encourage health care providers to limit referrals to specialty providers, expensive laboratory services, or to outpatient and inpatient care outside the system. A goal of reducing expenditures by limiting referrals may conflict with sound clinical judgment and compromise the quality of life for some patients, especially the elderly with chronic conditions. Nurses need to be aware of possible conflict of interests when working within managed care organizations and to advocate for norms and standards of clinical practice that can be legally enforced when such conflicts arise.