America's health care is undergoing a revolution. A previous private, fee-for-service, delivery system chiefly centered around hospital specialty care is rapidly being replaced by a commercialized system of managed care, controlled by businessmen whose prime motive is profit. Increasing emphasis of these managed care organizations is upon primary physicians who function as gatekeepers. While this new commercialized method of health care has been attended with reductions in the previous omnipresent health care inflation our country has experienced for the past several decades, its impact on quality of care and patient choice of physician remain a great concern. Especially vulnerable in this new system are our nation's academic centers, which, burdened with responsibility for education and research, are at a disadvantage in the competitive cost-based bidding for managed care contracts. Urology work force issues and the number of urologists in our nation remain another concern for urologists as they compete for access to patients in this new highly competitive environment. In a 1995 survey of a cohort of urologists in seven states, the respondents reported 35.8% of gross income came from managed care contracts, 86% reported the need for preservice approval for many diagnostic and therapeutic undertakings, 87% reported an inability to refer complex cases outside the Managed Care Organization (MCO) network, and 23% reported they were required to retain patients for treatment who they would have otherwise referred to a more qualified urologist. The majority of American urologists are reporting dropping gross revenues and increasing overhead in their dealings with managed care contracts. The advent of managed care is being attended with dropping gross revenues, increasing overhead costs and interference with the practice patterns of American urologists.
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