Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey

OBJECTIVE: To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity. DATA SOURCES/STUDY SETTING: Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate. STUDY DESIGN: Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers. DATA COLLECTION: We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA). PRINCIPAL FINDINGS: We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89. CONCLUSIONS: It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.     

Development of a measure of physician engagement in addressing racial and ethnic health care disparities

OBJECTIVE: To develop a measure of physician engagement in addressing health care disparities. DATA SOURCES/STUDY DESIGN: Cross-sectional survey of a national sample of physicians assessing each hypothesized component of engagement (Awareness, Reflection/Empowerment, and Action [AREA]). DATA COLLECTION/EXTRACTION METHODS: Results examined using factorial analysis; predictive validity of final scale examined among highly engaged physicians. PRINCIPAL FINDINGS: A nine-item scale derived from the AREA model has face validity, content validity, and applicability to a diverse group of physicians in measuring engagement. Partial correlations confirmed the mediating role of Reflection and/or Empowerment between Awareness and Action. Use of the scale among expert physicians suggests it reliably detects highly engaged physicians. CONCLUSIONS: A nine-item survey can measure physician engagement in addressing health care disparities.     

Patients' preferences for technical versus interpersonal quality when selecting a primary care physician

OBJECTIVE: To assess patients' use of and preferences for information about technical and interpersonal quality when using simulated, computerized health care report cards to select a primary care provider (PCP). DATA SOURCES/STUDY SETTING: Primary data collected from 304 adult consumers living in Los Angeles County in January and February 2003. STUDY DESIGN/DATA COLLECTION: We constructed computerized report cards for seven pairs of hypothetical individual PCPs (two internal validity check pairs included). Participants selected the physician that they preferred. A questionnaire collected demographic information and assessed participant attitudes towards different sources of report card information. The relationship between patient characteristics and number of times the participant selected the physician who excelled in technical quality are estimated using an ordered logit model. PRINCIPAL FINDINGS: Ninety percent of the sample selected the dominant physician for both validity checks, indicating a level of attention to task comparable with prior studies. When presented with pairs of physicians who varied in technical and interpersonal quality, two-thirds of the sample (95 percent CI: 62, 72 percent) chose the physician who was higher in technical quality at least three out of five times (one-sample binomial test of proportion). Age, gender, and ethnicity were not significant predictors of choosing the physician who was higher in technical quality. CONCLUSIONS: These participants showed a strong preference for physicians of high technical quality when forced to make tradeoffs, but a substantial proportion of the sample preferred physicians of high interpersonal quality. Individual physician report cards should contain ample information in both domains to be most useful to patients.     

A Comparative Assessment of West Virginia's Financial Incentive Programs for Rural Physicians

ABSTRACT: Context: Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes. Purpose: The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages. Methods: Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted. Findings: Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer Family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training. Conclusions: Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.     

Trust in the medical profession: conceptual and measurement issues

OBJECTIVE: To develop and test a multi-item measure for general trust in physicians, in contrast with trust in a specific physician. DATA SOURCES: Random national telephone survey of 502 adult subjects with a regular physician and source of payment. STUDY DESIGN: Based on a multidimensional conceptual model, a large pool of candidate items was generated, tested, and revised using focus groups, expert reviewers, and pilot testing. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. PRINCIPAL FINDINGS: The resulting 11-item scale measuring trust in physicians generally is consistent with most aspects of the conceptual model except that it does not include the dimension of confidentiality. This scale has a single-factor structure, good internal consistency (alpha = .89), and good response variability (range = 11-54; mean = 33.5; SD = 6.9). This scale is related to satisfaction with care, trust in one's physician, following doctors' recommendations, having no prior disputes with physicians, not having sought second opinions, and not having changed doctors. No association was found with race/ethnicity. While general trust and interpersonal trust are qualitatively similar, they are only moderately correlated with each other and general trust is substantially lower. CONCLUSIONS: Emerging research on patients' trust has focused on interpersonal trust in a specific, known physician. Trust in physicians in general is also important and differs significantly from interpersonal physician trust. General physician trust potentially has a strong influence on important behaviors and attitudes, and on the formation of interpersonal physician trust.     

The impact of financial incentives on physician productivity in medical groups

OBJECTIVE: To estimate the effect of financial incentives in medical groups--both at the level of individual physician and collectively--on individual physician productivity. DATA SOURCES/STUDY SETTING: Secondary data from 1997 on individual physician and group characteristics from two surveys: Medical Group Management Association (MGMA) Physician Compensation and Production Survey and the Cost Survey Area Resource File data on market characteristics, and various sources of state regulatory data. STUDY DESIGN: Cross-sectional estimation of individual physician production function models, using ordinary least squares and two-stage least squares regression. DATA COLLECTION: Data from respondents completing all items required for the two stages of production function estimation on both MGMA surveys (with RBRVS units as production measure: 102 groups, 2,237 physicians; and with charges as the production measure: 383 groups, 6,129 physicians). The 102 groups with complete data represent 1.8 percent of the 5,725 MGMA member groups. PRINCIPAL FINDINGS: Individual production-based physician compensation leads to increased productivity, as expected (elasticity = .07, p < .05). The productivity effects of compensation methods based on equal shares of group net income and incentive bonuses are significantly positive (p < .05) and smaller in magnitude. The group-level financial incentive does not appear to be significantly related to physician productivity. CONCLUSIONS: Individual physician incentives based on own production do increase physician productivity.     

The impact of S-CHIP enrollment on physician participation in Medicaid in Alabama and Georgia

OBJECTIVE: To assess whether increasing enrollment in State Children's Health Insurance Programs (S-CHIPs) has an impact on the number of office physicians participating in Medicaid and the extent of their participation. Effects are measured for a freestanding S-CHIP program with an open provider panel and an S-CHIP program that uses the state's Medicaid provider panel. DATA SOURCES: Children's Medicaid claims data for primary care services were used to measure physician participation in the program; census and enrollment data were used to describe market area characteristics. Study Design. This is a time series study of communities in two states, measuring physician Medicaid participation quarterly between 1998 and 2001, controlling for changes in community characteristics and children's program enrollment as well as other factors by quarter. DATA COLLECTION/EXTRACTION: Office physician participation is measured by practice site. Claims data are aggregated to the level of the community and reflect the number of limited practice sites, the ratio of Medicaid office sites to the number of primary care physicians in the community as reported by the American Medical Association (AMA), and the mean number of Medicaid office visits made to physician sites in the community in the quarter. FINDINGS: In Alabama, the state with a freestanding S-CHIP program, there is little association between increased S-CHIP enrollment and physician participation in Medicaid. In Georgia, where the same provider network serves both programs, increases in S-CHIP enrollment are associated with a decline in office-based physician participation in Medicaid in urban areas. CONCLUSION: Linkage of S-CHIP and Medicaid programs through the use of the same provider network, in the absence of market conditions that encourage the expansion of the network, can lead to a negative impact on access for Medicaid enrollees.     

Prepayment was superior to postpayment cash incentives in a randomized postal survey among physicians

OBJECTIVE: Improving response rates, particularly among physicians, is important to minimize nonresponder bias and increase the effective sample size in epidemiologic research. We conducted a randomized trial to examine the impact of prepayment vs. postpayment incentives on response rates. STUDY DESIGN AND SETTING: Self-completion postal questionnaires were mailed to 949 physicians who were respondents to an earlier survey and representative of the general physician population in Hong Kong. These physicians were randomly allocated to receive a HK dollar 20 cash prepayment incentive that accompanied the survey (n=474) or a postpayment reward of the same amount on receipt of the completed questionnaire (n=475). RESULTS: The final prepayment response rate was 82.9%, compared with 72.5% in the postpayment arm (P < .001). Of the eight alternative incentive and follow-up strategies evaluated, three lie on the efficiency frontier (i.e., not dominated), including postpayment with three mailings at HK dollar 42.7, prepayment with three mailings at HK dollar 66.5 and prepayment with three mailings and telephone follow-up at HK dollar 112.1 per responder recruited (US dollar 1=HK dollar 7.8). CONCLUSION: The findings demonstrate that prepayment cash incentives are superior to postpayment of the equivalent amount in improving response rates among a representative sample of Hong Kong physicians. Further research should concentrate on confirming the generalizability of these findings in other health care occupation groups and settings.     

Physician response rates to a mail survey by specialty and timing of incentive

BACKGROUND: Historically, achieving a high response rate on physician surveys has been a challenging task. Given such concerns, understanding research strategies that facilitate adequate response rates is important. Primary care physician responses to a mail survey on smoking cessation are summarized by physician specialty and timing of incentive. METHODS: A stratified random-sample design, stratified by patient populations-adults, adolescents, and pregnant women-was used. The sampling frame included New Jersey internists, general practitioners, family physicians, pediatricians, and obstetrician-gynecologists. A total of 2100 physicians, 700 physicians from each patient strata, were sampled and mailed a smoking-cessation survey in summer 2002. The sample was randomized by incentive timing: Half received the incentive (i.e., 25 dollars gift card) with the first survey mailing, and half received the incentive on receipt of their completed survey. RESULTS: The promised-incentive group achieved a significantly lower response rate (56%) compared with the up-front-incentive group (71.5%). Response rates by medical specialty varied overall and within incentive groups. The difference between the incentive groups was greatest among obstetrician-gynecologists (i.e., 20.2 percentage points) and was least among pediatricians (i.e., 5.8 percentage points). CONCLUSIONS: Physician response rates to mail surveys are greatly improved, especially among certain medical specialties, by using up-front incentives.     

Developing a Japanese hospital physician satisfaction scale

PURPOSE: Hospital physician shortages are widely recognized as a national problem in Japan. Although physician job satisfaction has a relationship with service quality and physician turnover, there is no measure to assess Japanese hospital physician satisfaction. This paper aims to establish a measure of job satisfaction for Japanese hospital physicians and evaluated its psychometric performance. DESIGN/METHODOLOGY/APPROACH: Two cross-sectional physician surveys were used--a pilot survey, conducted as a self-administered questionnaire; and a validation survey conducted on-line. FINDINGS: A total of 82 hospital physicians completed the pilot questionnaire. Factor and reliability analyses produced a 28-item, 6-subscale and 2-global satisfaction scale measure, the Japan hospital physicians satisfaction scale (HPSS). Results supported the measure's reliability and validity. For the validation survey, 146 hospital physicians completed the online questionnaire. One question item was substituted following factor analysis. Results also displayed the measure's adequate psychometric properties. RESEARCH LIMITATIONS/IMPLICATIONS: Participating physicians were convenience samples, which may not fully represent Japanese hospital physicians. ORIGINALITY/VALUE: The JHPSS, a brief questionnaire measuring Japanese hospital physician job satisfaction, should be useful for providing better quality care and improving our understanding of and ability to deal with Japanese hospital workforce issues.     

Validity and reliability of the Vietnamese Physician Professional Values Scale

Physician values influence a physician’s clinical practice and level of medical professionalism. Currently, there is no psychometrically valid scale to assess physician values in Vietnam. This study assessed the initial validity and reliability of the Vietnamese Physician Professional Values Scale (VPPVS). Hartung’s original Physician Values in Practice Scale (PVIPS) was translated from English into Vietnamese and adapted to reflect the cultural values of Vietnamese physicians. A sample of clinical experts reviewed the VPPVS to ensure face and content validity of the scale, resulting in a draft 37-item measure. A cross-sectional survey of 1086 physicians from Hanoi, Hue and Ho Chi Minh City completed a self-report survey, which included the draft of the VPPVS. Exploratory Factor Analysis was used to assess construct validity, resulting in 35 items assessing physician’s professional values across five main factors: lifestyle, professionalism, prestige, management and finance. The final five-factor scale illustrated acceptable internal consistency, with Cronbach’s alpha coefficients ranging from 0.73 to 0.86 and all item-total correlations >0.2. Limited floor or ceiling effects were found. This study supports the application of the VPPVS to measure medical professional values of Vietnamese physicians. Future studies should further assess the psychometric properties of the VPPVS using large samples.     

Practical issues in the design and implementation of pay-for-quality programs

Health plans, healthcare purchasers, and provider organizations throughout the United States are crafting pay-for-performance programs with the intent of improving the quality of care and with recognition of the need to restrain rapidly rising costs. Health plans and large, self-insured employers have typically led the movement toward using quality scorecards with which to gauge hospital and physician performance, coupled with the use of financial incentives directed at hospitals, physician group practices, and individual physicians and practice teams. In this article we provide a conceptual perspective for understanding the objectives and constraints of payers and providers as they wrestle with the next generation of pay-for-quality (P4Q) programs. We identify a set of practical issues that must be addressed in developing and conducting P4Q programs in different market environments. Those issues include specific strategies for choosing quality metrics, units of accountability, size of incentive, data and measurement systems, payout formulas, and collaboration among payers. We illuminate these issues by considering different approaches in light of real-world P4Q demonstrations underway in the Rewarding Results program, in Bridges to Excellence program, and in specific provider organizations we interviewed over the years. The discussion of practical issues highlights principles and examples directly relevant to hospitals and physician organizations that are considering participation in P4Q as well as to those reexamining their physician compensation mechanisms.     

Primary care physician turnover in HMOs.

OBJECTIVE. We assess whether physician turnover stems from incorrect physician expectations about the practice environment or from actual constraints or rewards in that environment. DATA SOURCES. Our primary data source contains information about individual HMOs' primary care physicians incentive mechanisms and general HMO characteristics. Our secondary data source is the area resource file (ARF), which contains countywide information about the HMOs' market areas, including physician characteristics, population characteristics, and other market characteristics. DATA COLLECTION. Our primary data source is from a nationwide survey of all HMOs in operation in 1987-1988, as reported to Interstudy. PRINCIPAL FINDINGS. We find that turnover is higher on the part of physicians whose HMO enrollment comprises a greater percentage of their total practice. Our results further indicate that physicians whose compensation is dependent on the behavior of a group of other physicians are more likely to leave the plan than those who bear the risk (and control it) more directly. On the other hand, turnover is increased by basing bonuses on individual productivity and by not sharing surpluses among a group. Market characteristics also are significant in explaining physician turnover in HMOs. CONCLUSIONS. It appears that physicians accurately forecast how they will react to individual financial risk, although they dislike restrictions imposed by HMOs.     

Development and Initial Validation of an Instrument to Measure Physician–Pharmacist Collaboration from the Physician Perspective

OBJECTIVE: Using a conceptual model of collaborative working relationships between pharmacists and physicians, a measure for physician-pharmacist collaboration from the physician perspective was developed. The measure was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. METHODS: An initial 27-item Physician-Pharmacist Collaboration Instrument (PPCI) was developed to assess seven themes about professional relationships using Likert scales. The PPCI was mailed to a random sample of 1000 primary care physicians. Principal component analysis was used to assess the structure and uncover underlying dimensions of the initial instrument. Items were evaluated for inclusion or exclusion into a refined instrument. Internal consistency was assessed by calculating Alpha coefficients for each identified factor. Convergent validity was assessed using Spearman correlations between the identified factors and a previous measure of collaborative care. After measure refinement, confirmatory factor analysis was used to evaluate the fit of both versions of the instrument. RESULTS: Three hundred forty usable surveys were returned for a response rate of 34%. Almost 70% of the respondents were male with a mean age of 45.8. A majority were family practice physicians (72.1%) in private practice (67.3%). Three unique factors were identified during principal component analysis and utilized in a confirmatory factor analysis. Both a full and a 14-item reduced model were constructed and tested. Cronbach's alpha for the three factors of the full model ranged from 0.91 to 0.97, while the reliability for the reduced model ranged from 0.86 to 0.96. Comparative fit indexes of 0.97 and 0.98 were obtained, indicating good fit for the models. CONCLUSIONS: The results indicate good reliability and validity of the refined (14-item) PPCI. This instrument can be useful as a research tool for assessment of the physicians' perspective about a physician-pharmacist relationship. Further research is warranted to examine if the extent of relationship development, as measured with the PPCI, can affect patient care outcomes.     

Development of a scale to measure patients' trust in health insurers

OBJECTIVE: To develop a scale to measure patients' trust in health insurers, including public and private insurers and both indemnity and managed care. A scale was developed based on our conceptual model of insurer trust. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties. DATA SOURCES/STUDY SETTING: The scale was developed and validated on a random national sample (n = 410) of subjects with any type of insurance and further validated and used in a regional random sample of members of an HMO in North Carolina (n = 1152). STUDY DESIGN: Factor analysis was used to uncover the underlying dimensions of the scale. Internal consistency was assessed by Cronbach's alpha. Construct validity was established by Pearson or Spearman correlations and t tests. DATA COLLECTION: Data were collected via telephone interviews. PRINCIPAL FINDINGS: The 11-item scale has good internal consistency (alpha = 0.92/ 0.89) and response variability (range = 11-55, M = 36.5/37.0, SD = 7.8/7.0). Insurer trust is a unidimensional construct and is related to trust in physicians, satisfaction with care and with insurer, having enough choice in selecting health insurer, no prior disputes with health insurer, type of insurer, and desire to remain with insurer. CONCLUSIONS: Trust in health insurers can be validly and reliably measured. Additional studies are required to learn more about what factors affect insurer trust and whether differences and changes in insurer trust affect actual behaviors and other outcomes of interest.     

Does physician weight affect perception of health advice?

BACKGROUND: Obesity is considered a growing health threat in the United States. Although physicians have an important role in counseling their patients for obesity prevention and treatment, physicians themselves are often overweight. There are few data regarding how physician body weight might affect patient receptiveness to obesity counseling. METHODS: A 43-item survey instrument was developed that consisted of three scales related to physician characteristics, health locus of control, and perceptions on receiving health advice from overweight physicians. The survey was administered to 226 patients in five physician offices. Two of the physicians were classified as obese using BMI calculations, and three were nonobese. The responses from the surveys were grouped into those from obese and nonobese physicians. RESULTS: Significant differences were found for patient receptiveness to counseling for treatment of illness (P = 0.038) and health advice (P = 0.049), with the patients of nonobese physicians indicating greater confidence scores. The difference for weight and fitness counseling did not reach significance (P = 0.075). Analysis revealed that patient BMI was not a significant covariate nor were items related to physician characteristics in general or health locus of control. CONCLUSIONS: Patients seeking care from nonobese physicians indicated greater confidence in general health counseling and treatment of illness than patients seeing obese physicians. It is not known if this can be translated into increased success in obesity prevention and treatment.     

Primary care physician perceptions of the nurse practitioner in the 1990s.

OBJECTIVE: To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care. DESIGN: A mailed survey of primary care physicians in Iowa. SETTING AND PARTICIPANTS: Half (N = 616) of the non-institutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n = 259 [42.0%]). MAIN OUTCOME MEASURES: There were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by chi 2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs. RESULTS: In bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P < .001), had been in practice for fewer than 20 years (P = .045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P = .01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P = .03), and general practice physicians (P = .04) had significantly more favorable attitudes toward NPs than did other primary care physicians. CONCLUSIONS: The association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.     

Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study

OBJECTIVE: To study the impact that physician, practice, and patient characteristics have on physician stress, satisfaction, mental, and physical health. DATA SOURCES: Based on a survey of over 5,000 physicians nationwide. Four waves of surveys resulted in 2,325 complete responses. Elimination of ineligibles yielded a 52 percent response rate; 1,411 responses from primary care physicians were used. STUDY DESIGN: A conceptual model was tested by structural equation modeling. Physician job satisfaction and stress mediated the relationship between physician, practice, and patient characteristics as independent variables and physician physical and mental health as dependent variables. PRINCIPLE FINDINGS: The conceptual model was generally supported. Practice and, to a lesser extent, physician characteristics influenced job satisfaction, whereas only practice characteristics influenced job stress. Patient characteristics exerted little influence. Job stress powerfully influenced job satisfaction and physical and mental health among physicians. CONCLUSIONS: These findings support the notion that workplace conditions are a major determinant of physician well-being. Poor practice conditions can result in poor outcomes, which can erode quality of care and prove costly to the physician and health care organization. Fortunately, these conditions are manageable. Organizational settings that are both "physician friendly" and "family friendly" seem to result in greater well-being. These findings are particularly important as physicians are more tightly integrated into the health care system that may be less clearly under their exclusive control.     

Incentives and the management of physician behavior in health service organizations

The performance of a health services organization is affected by the cumulative behavior of physicians out of proportion to their numbers or the economic value of their services. Managers are challenged to optimize physician behavior and to change it in concert with the evolving expectations of health service customers. Incentives are the tools available for this effort. This article discusses the interrelation of physician behavior, physician needs, and the major classes of incentives: economic, noneconomic, and rules. While most organizations recognize and use financial incentives, few utilize noneconomic incentives systematically. Given the financial restrictions of advanced markets, managers should understand the role of rules and the value of noneconomic issues to physicians when developing incentive programs.     

Regional and individual differences in physician practices for joint-ventured versus non-joint-ventured physicians.

OBJECTIVE. This article compares characteristics of physicians who have invested in health care business (joint ventures) to characteristics of physicians who have not, based on a survey of Florida physicians. DATA SOURCES/STUDY SETTING. In early 1990, a survey was mailed to a stratified random sample of 1,000 Florida physicians. Half were randomly selected from lists of joint-ventured physicians who had been identified as owners in a previous study by the Florida Health Care Cost Containment Board. The remaining half were assumed to be non-joint-ventured (although incomplete results from the previous study meant that some of these physicians would be joint ventured as well). We tagged survey variables with additional variables from the same year representing exogenous influences. STUDY DESIGN. The survey was mailed to a stratified random sample of physicians across specialty and geographic area, with half to identified joint-ventured physicians and half to a control group, some of whom were expected to be joint-ventured. Thus, results regarding differences would be understated. Key variables include referring versus nonreferring physician, to shed light on motivation for joint-venturing; clientele served, to see if systematic differences had implications related to access for poor or underserved persons; geographic area, to see if joint-ventures were undertaken to increase access in rural areas; and other practice variables such as size and type of practice. DATA COLLECTION/EXTRACTION METHODS. Data from all received surveys were encoded and analyzed using SPSS. Incomplete surveys were also encoded so that all information would be available for possible use. PRINCIPAL FINDINGS. Results indicate that joint-ventured physicians are more likely than non-joint-ventured physicians to be referring physicians. Also, joint-ventured physicians report serving lower proportions of Medicaid and self-pay (uninsured) patients and higher proportions of Medicare patients. Joint-ventured physicians are also more likely to practice in urban areas, to practice full time, to be members of larger practices, and to practice in group practices. Further, joint-ventured physicians are more likely to practice in areas with high proportions of Medicare patients. CONCLUSIONS. Policymakers should continue to regard physician joint ventures as problematic, since results of this study indicate that physicians who engage in a joint venture almost always have the ability to refer patients to that joint venture due to the nature of their practices. Results also show that joint ventures are associated with decreased access: that is, they provide care to lower proportions of poor and underserved patients and rural patients than their non-joint ventured counterparts.