The impact of managed care and practice size on primary care physicians' perceived ability to refer

OBJECTIVES: To identify the determinants of primary care physicians' perceived ability to refer patients, to compare perceived ability to refer between solo/two-physician practices and group practices, and to determine the impact of managed care on perceived ability to refer. METHODS: Multivariate analysis using a dataset derived from the Community Tracking Study Physician Survey, 1996-1997. The variables used to explain physicians' perceived ability to refer included physician and practice characteristics as well as aspects of the financial arrangements of managed care. The sample was stratified by practice size. A likelihood ratio test was performed to determine whether there were differences in practice characteristics and managed care financial arrangements that could explain variations in perceived ability to refer between physicians in solo/two-physician and group practices. RESULTS: Perceived ability to refer did not vary much between physicians in solo/two-physician practices and those in group practices. However, the determinants of perceived ability to refer did vary by practice size. The effects of physicians' characteristics were more pronounced among physicians in group practice, whereas the effects of financial arrangements were significant for physicians in solo/two-physician practices. The most significant determinant of perceived ability to refer was primary care physicians' satisfaction in their communication with specialists. CONCLUSION: Group practices are more immune than solo/two-physician practices to external financial arrangements from managed care contracts, possibly through their ability to take advantage of economies of scale and to diversify their sources of funds.     

Impact of practice arrangements on physicians' satisfaction

This research examines the effect of practice arrangements on five dimensions of physicians' satisfaction (i.e., personal factors, resources, peer review, profession, and state regulations) and the moderating effect of job autonomy and decision making on this relationship. This research finds that physicians who work for HMOs and hospitals are more satisfied with job resources, regulatory climate, and their professions, compared with physicians who are self-employed (solo and group practices). Physicians who work for HMOs and hospitals have less autonomy and decision-making power, compared with self-employed physicians. Also, job autonomy partially moderates the relationship between organizational arrangement and physicians' satisfaction with job resources and satisfaction with the profession. Decision making does not moderate the organizational arrangement and physicians' satisfaction relationship.     

Physician satisfaction in a managed care environment.

BACKGROUND. The professional literature suggests that changes toward the bureaucratization of medical practice have led to increasing job dissatisfaction, especially in primary care. To investigate this claim, we surveyed physicians in Dane County, Wisconsin, who practice in a bureaucratic setting. Dane County has experienced essentially a demise in independent practice, ie, most physicians practice in organizational settings where expenses and total patient income are pooled. About 85% of physicians have joined one of the six competing health maintenance organizations (HMOs). METHODS. In 1986 all 850 physicians in Dane County were surveyed to determine their perceptions of clinical freedom, satisfaction with income, status in their profession, autonomy, resources, and professional relations, and their overall satisfaction. RESULTS. We found that over 69% of primary care physicians were very satisfied or satisfied with their practices overall compared with 68% of physicians in all specialties. Differences between family practice and other primary care specialties were not statistically significant. Our regression analysis showed that only for satisfaction with income were responses from primary care physicians significantly different from those of physicians in surgical specialties. Perceptions of clinical autonomy and specific organizational settings were more important to predicting satisfaction. Also, age and sex contributed to differences in satisfaction with resources and status, respectively. CONCLUSIONS. We conclude that satisfaction can be fairly high for primary care physicians in bureaucratic settings similar to that of Dane County.     

Conceptual Blockbusters: Creative Idea Generation Techniques for Health Administrators

This research examines the effect of practice arrangements on five dimensions of physicians' satisfaction (i.e., personal factors, resources, peer review, profession, and state regulations) and the moderating effect of job autonomy and decision making on this relationship. This research finds that physicians who work for HMOs and hospitals are more satisfied with job resources, regulatory climate, and their professions, compared with physicians who are self-employed (solo and group practices). Physicians who work for HMOs and hospitals have less autonomy and decision-making power, compared with self-employed physicians. Also, job autonomy partially moderates the relationship between organizational arrangement and physicians' satisfaction with job resources and satisfaction with the profession. Decision making does not moderate the organizational arrangement and physicians' satisfaction relationship.     

Primary care gatekeepers in HMOs

The most pressing issue in health care delivery today is inflationary cost increases. The gatekeeping role of primary care physicians, particularly family physicians, may lower health care costs through a more judicious use of specialty referrals, expensive tests, and hospitalization. The study of such an impact is most readily carried out in the practice setting of health maintenance organizations (HMOs), where there is a defined patient population. Incomplete data and lack of sensitive indicators of the gatekeeping effect are limitations of this preliminary study. The results show, however, that the internal organization of an HMO does not influence hospital and ambulatory care utilization rates, with the exception that HMOs staffed by a group of salaried physicians (staff HMOs) reported higher ambulatory care utilization. No significant differences were demonstrated in hospital or ambulatory care utilization rates among the HMOs using more primary care physicians or family physicians than others. The results indicate that ambulatory care utilization rates are proportional to the number of physicians per 1,000 members. The results also suggest that there may be an inverse relationship between hospital utilization rates and the number of primary care physicians, especially if they are family physicians. Further studies need more specific indicators to evaluate the effect of the gatekeeping role in health care delivery.     

Physicians' perspectives of HMOs and marketing: implications and recommendations

The authors compare physicians in HMOs and those not in HMOs in order to determine how HMOs have affected their practices. Physicians in HMOs see more patients per day, but receive less income per patient than physicians not in HMOs; however, both groups of physicians agree that HMOs have not changed marketing practices. In fact, both groups report uncertainty as to the best way to market their practice, and in their understanding of marketing. The physicians do agree that patient referrals are the most important means of patient acquisition; however, both groups report a surprisingly low use of patient questionnaires. Implications and recommendations for HMOs, physicians, and health care marketing researchers are discussed.     

Physicians' Perspectives of HMOs and Marketing

The authors compare physicians in HMOs and those not in HMOs in order to determine how HMOs have affected their practices. Physicians in HMOs see more patients per day, but recieve less income per patient than physicians not in HMOs; however, both groups of physicians agree that HMOs have not changed marketing practices. In fact, both groups report uncertainty as to the best way to market their practice, and in their understanding of marketing. The physicians do agree that patient referrals are the most important means of patient acquisition; however, both groups report a surprisngly low use of patient questionnaires. Implications and recommendations for HMOs, physicians, and health care marketing researchers are discussed.     

Solo and Small Practices: A Vital,Diverse Part of Primary Care

PURPOSE

Solo and small practices are facing growing pressure to consolidate. Our objectives were to determine (1) the percentage of family physicians in solo and small practices, and (2) the characteristics of and services provided by these practices.

METHODS

A total of 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 completed a demographic survey. Their practices were split into categories by size: solo, small (2 to 5 providers), medium (6 to 20 providers), and large (more than 20 providers). We also determined the rurality of the county where the physicians practiced. We developed 2 logistic regression models: one assessed predictors of practicing in a solo or small practice, while the other was restricted to solo and small practices and assessed predictors of practicing in a solo practice.

RESULTS

More than one-half of respondents worked in solo or small practices. Small practices were the largest group (36%) and were the most likely to be located in a rural setting (20%). The likelihood of having a care coordinator and medical home certification increased with practice size. Physicians were more likely to be practicing in small or solo practices (vs medium-sized or large ones) if they were African American or Hispanic, had been working for more than 30 years, and worked in rural areas. Physicians were more likely to be practicing in small practices (vs solo ones) if they worked in highly rural areas.

CONCLUSIONS

Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies. Extension programs and community health teams have the potential to support transformation within these practices.     

Primary care physician incentives in medical group practices

CONTEXT: Although medical groups are adapting to changes in financing health care, little is known about individual physician incentives in this environment. OBJECTIVES: To describe methods group practices use to compensate primary care physicians in a managed care environment and to examine the association of revenue sources for the group practice from all patients and primary care physician incentives. DESIGN: We surveyed by mail group practice administrators for practices that had at least 200 members continuously enrolled in 1995. SETTING: Group practices that had contractual arrangements with Blue Cross/Blue Shield of Minnesota. PARTICIPANTS: One hundred of 129 group practices returned usable surveys. RESULTS: Most groups had some portion of primary care physicians' compensation at risk, although 17 groups compensated them through fully guaranteed annual salary. Seventy-one groups used productivity, 4 groups used quality of care, 1 group used utilization, and 30 used group financial performance. Factors reported to significantly influence primary care physician compensation included billings or charges, overall group practice performance, and net revenue or profit. Groups that had a higher proportion of income from various types of fee-for-service arrangements used lower proportions of base salary for primary care physician compensation and were more likely to relate physician income to measures of productivity. CONCLUSIONS: Substantial variation exists in the types of primary care physician incentives implemented by medical groups. Base salary, individual productivity, and group financial performance were most frequently used to determine compensation. Physician personal financial risk was higher overall in group practices that derived more revenue from fee-for-service contracts.     

Do group practices have lower caesarean rates than solo practice obstetric clinics? Evidence from Taiwan

OBJECTIVE: This study examined physicians' propensity for caesarean deliveries at solo versus group practice obstetrics/gynaecology (ob/gyn) clinics in Taiwan. METHOD: We used population-based (National Health Insurance) claims data covering all 253 618 singleton deliveries conducted at ob/gyn clinics, during 2000-02. The dependent variable, delivery mode, was treated as dichotomous [caesarean section (CS) = 1, vaginal delivery (VD) = 0]. The independent variable of interest was practice size, classified into four categories: 1, 2, 3 and 4+ physicians. Multilevel logistic regression modelling, accounting for clinic-level variation in CS rates, was used to examine CS likelihood by practice size, among the total delivery sample and among the sub-samples disaggregated by obstetric complication status. RESULTS: Solo practices have 7% excess caesarean cases relative to large group practices. After controlling for patient's age, physician demographics, the clinic's geographic location and size of delivery service, and clinic-level random effect, solo practice physicians were 5.38 times as likely as 4+ physician practices to provide caesarean delivery (CI = 4.18 approximately 6.93), 2-physician practices were 3.87 times (CI = 2.99 approximately 5.01) and 3-physician practices 2.72 times (CI = 2.06 approximately 3.59) as likely as 4+ physician practices to provide caesarean delivery. This effect is driven by higher CS propensity among solo and small groups among cases with obstetrically less salient complications and the 'no complications' subset of patients. Wide confidence intervals for odds ratios in these sub-samples also attest to wide variations in clinic-level CS rates among these patient groups. CONCLUSIONS: Solo physicians are the most likely to provide caesarean delivery, and CS likelihood decreases with increasing number of physicians in the practice. Group practice support may reduce the CS likelihood, when it is not clinically indicated. Policy makers should consider initiatives to limit full service delivery privileges to group practice obstetric clinics, in order to reduce unnecessary CS. Solo practice clinics should, at best, be licensed as birthing centres, required to transfer patients needing CS to a larger facility.     

Satisfaction and well-being of primary care providers in managed care

We compared perceptions about the practice environment and the job satisfaction of physician assistants (PAs), nurse practitioners (NPs), and primary care physicians in a large group-model HMO. The data source was a self-administered mail survey (average response rate = 79%). PA/NPs and primary care physicians reported that professional autonomy was not a problem and were satisfied with most aspects of practice in this setting. Common areas of dissatisfaction included patient load and amount of time with patients. PA/NPs were more likely than the physicians to experience stress on a daily basis, however, and were less likely to report that they would choose the practice setting again. They also were significantly less satisfied than the physicians with their incomes and fringe benefits. Our findings suggest that more attention should be given to practice conditions and compensation of PAs and NPs in managed care.     

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.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

Comparing the characteristics and attitudes of physicians in different primary care settings: The Ontario Walk-in Clinic Study

BACKGROUND: In Canada, walk-in clinics (WICs) are a focus for debate about access to and the costs and quality of primary care. While WICs may offer patients easier access through longer hours and shorter waits, it has been argued that they may also lead to unnecessary utilization, duplication of services, lack of continuity of care, decreased quality and increased costs. OBJECTIVES: The main objectives were to analyse the characteristics and attitudes of physicians working in different family practice types including WICs. METHODS: We analysed the results of a 1998 survey of 728 primary care physicians in Ontario to compare physicians working in WICs with those working in solo and group family practices. RESULTS: Our survey found that few physicians worked most or all of their hours in WICs; most worked in WICs and other family practice types. Compared to family physicians in solo and group practices, physicians working in WICs saw more patients who were not their regular patients, patients without appointments and children. They reported slightly higher frequencies of problems such as backlogs (patient queues) and patients who had sought care from other doctors for the same problem. WIC physicians were less satisfied than other physicians with their relations with patients. They were, however, more satisfied with the availability of consultation, support staff, hours, income, and vacation coverage. Further, WIC physicians assessed the quality of care in WICs to be neither better nor worse than that in other family practices. CONCLUSIONS: We conclude that there are important similarities as well as differences, between physicians in WICs and those in more conventional family practices. The assessments of primary care physicians do not support the generally negative reputation of WICs. Instead, greater consideration should be given to the system-level issues which produce demand for WICs.     

Physician organization and care management in California: from cottage to Kaiser

Data from a survey of practicing physicians in California's thirteen largest urban counties were used to ascertain differences in care management processes, financial incentives for quality, and practice pressures by type of practice setting. Physicians in the Permanente medical groups have adopted and value quality-oriented, system-level care management tools to a much greater degree than physicians in independent practice association (IPA) networks or traditional "cottage-industry" practices. Our findings raise disturbing questions about how the health system will close the "quality chasm" in medical care without transforming the underlying organization of physician practices.     

Cutting out the middleman: physicians can contract directly with employers--a viable alternative to adversarial managed care agreements

HMOs, PPOs, and other managed care "middlemen" control the means by which most physicians do business with employers. As physicians face dwindling reimbursements, greater practice restrictions, and increased pressure to sign adversarial middleman contracts, interest in direct contracting has grown. This article introduces direct contracting as an important alternative to commercial managed care agreements; cites the key advantages and process of direct contracting; and offers practical recommendations for helping physician practices successfully negotiate direct physician/employer agreements.     

Competition,gatekeeping, and health care access

We study gatekeeping physicians’ referrals of patients to specialty care. We derive theoretical results when competition in the physician market intensifies. First, due to competitive pressure, physicians refer patients to specialty care more often. Second, physicians earn more by treating patients themselves, so refer patients to specialty care less often. We assess empirically the overall effect of competition with data from a 2008–2009 Norwegian survey, National Health Insurance Administration, and Statistics Norway. From the data we construct three measures of competition: the number of open primary physician practices with and without population adjustment, and the Herfindahl–Hirschman index. The empirical results suggest that competition has negligible or small positive effects on referrals overall. Our results do not support the policy claim that increasing the number of primary care physicians reduces secondary care.     

Characteristics of medical practices in three developed managed care markets

OBJECTIVE: To describe physician practices, ranging from solo and two-physician practices to large medical groups, in three geographically diverse parts of the country with strong managed care presences. DATA SOURCES/STUDY DESIGN: Surveys of medical practices in three managed care markets conducted in 2000-2001. STUDY DESIGN: We administered questionnaires to all medical practices affiliated with two large health plans in Boston, MA, and Portland, OR, and to all practices providing primary care for cardiovascular disease patients admitted to five large hospitals in Minneapolis, MN. We offer data on how physician practices are structured under managed care in these geographically diverse regions of the country with a focus on the structural characteristics, financial arrangements, and care management strategies adopted by practices. DATA COLLECTION: A two-staged survey consisting of an initial telephone survey that was undertaken using CATI (computerized assisted telephone interviewing) techniques followed by written modules triggered by specific responses to the telephone survey. PRINCIPAL FINDINGS: We interviewed 468 practices encompassing 668 distinct sites of care (overall response rate 72 percent). Practices had an average of 13.9 member physicians (range: 1-125). Most (80.1 percent) medium- (four to nine physicians) and large-size (10 or more physicians) groups regularly scheduled meetings to discuss resource utilization and referrals. Almost 90 percent of the practices reported that these meetings occurred at least once per month. The predominant method for paying practices was via fee-for-service payments. Most other payments were in the form of capitation. Overall, 75 percent of physician practices compensated physicians based on productivity, but there was substantial variation related to practice size. Nonetheless, of the practices that did not use straight productivity methods (45 percent of medium-sized practices and 54 percent of large practices), most used arrangements consisting of combinations of salary and productivity formulas. CONCLUSIONS: We found diversity in the characteristics and capabilities of medical practices in these three markets with high managed care involvement. Financial practices of most practices are geared towards rewarding productivity, and care management practices and capabilities such as electronic medical records remain underdeveloped.     

Wyoming physicians are significant providers of safety net care

BACKGROUND: This study describes the contributions of family and general practice physicians from Wyoming to the health care safety net. METHODS: We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. Two-tailed chi(2) tests and limited logistic regressions were used to test for differences among characteristics of safety net providers. RESULTS: From a 50% response rate, 61% made less than the national mean family physician income (USD$130,000), and women are less likely than men to make this mean income, even when controlling for hours worked (OR, 0.09; CI, 0.009, 0.862). Close to two thirds claimed bad debt of over USD $10,000, and 29.3% noted forgiven debt of over USD $10,000. Physicians with less income than the prior year were more likely to decrease their charity care. CONCLUSIONS: Wyoming family and general practice physicians provide significant amounts of informal safety net care, which is threatened by income loss. Thoughtful public policy is needed to ensure that vulnerable rural Americans have access to care that is not tied to the financial well being of their health care providers.