| The federal government is the largest purchaser of health care services in the United States. The Centers for Medicare and Medicaid Services, while beset with increased costs in health care, is charged to contain spending. A myriad of efforts focusing on physicians have met with only limited success at containing health care cost. Efforts at cost containment have ignored the impact of medical office insurance staff members as actors in the implementation of Medicare policy. These staff members, acting as physicians' agents in medical practices, are significant in shaping outcomes of Medicare policy. This study provides understanding about how insurance staff members make decisions relating to Medicare reimbursement, how complexity influences organizations, and how individuals working in ambiguous and complex situations make sense of their work environment.;Data from interviews with medical office insurance staff members indicate that their behavior is consistent with the behavior of street-level bureaucrats. The complexity and ambiguity of their working environment drives them to engage in the act of sensemaking, as described by Weick, as they seek to understand what is happening around them and bring sensible meaning to their work world. Non-routine work situations cause staff members to develop strategies to cope with the work situations. Insurance staff members face two major tensions in their work—the tension between independent and dependent behavior and the tension between being patient focused and organization focused. Faced with the critical dimensions of these tensions, staff members draw on their perceptions, attitudes, beliefs, and prior actions to serve as a behavioral guide to resolve confounding pressures. A sensemaking analysis of insurance staff members' behavior demonstrates how the general characteristics of their work situation, the tensions that frame their decision making and service delivery, and the consequences of their decisions support the conclusion that medical office insurance staff members act as street-level bureaucrats implementing Medicare policy. |
