Factors affecting primary care physicians' perceptions of health system reform in Israel: professional autonomy versus organizational affiliation

This paper examines primary care physicians' perceptions of a National Health Insurance Law that introduced managed competition into Israel's health care system, and the factors affecting their perceptions. Between April and July 1997, we conducted a mail survey of primary care physicians employed by Israel's four health plans (which are managed care organizations). Eight hundred questionnaires were returned, representing a response rate of 86%. The findings indicate that, overall most physicians support the components of the National Health Insurance Law with statistically significant differences among physicians by health plan. Multivariate analysis revealed that, contrary to theoretical expectations, a perceived decrease in professional autonomy and in the status of the profession following reform did not significantly affect attitudes toward national health insurance. These findings highlight the need for additional empirical studies to further examine theoretical contentions about the implications of infringing on the professional autonomy and the dominant status of physicians. The principal and most interesting finding of this study was the independent effect of health plan affiliation on physicians' attitudes toward each of the five components of the National Health Insurance Law, after controlling for background characteristics, for the reform's perceived effect on the physicians' autonomy and status in the health plan, and for the reform's perceived effect on the level of health plan services and the health plan's financial situation. We found that physicians' perceptions tended to conform to the formal position of their health plan, suggesting the need to analyze the attitudes of physicians in their organizational context, rather than treating them as members of a uniform professional community.     

Measuring the physician perspective on quality of care in health plans

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.     

The ACO paradox impacting physicians

Accountable care organizations (ACOs) would hold care providers jointly accountable for the quality and costs of care, allow consumers the freedom to choose their providers, and involve physicians and consumers in their shared decision-making. Even though the ACO model proposes physician empowerment, it also poses significant financial and change-management challenges for physicians. Furthermore, the "patient-centered" ACOs that have been established to safeguard consumer sovereignty pose the risks of concentrating healthcare markets further and exacerbating the existing disparities in healthcare. We conducted a survey study to understand physicians' perspectives of ACOs by seeking their first-hand feedback. The survey results suggest that there are significant communication gaps between physicians and healthcare administrators; and efficient communication can help improve physician-administrator alignment and help them identify opportunities that would be critical to the success of ACOs.     

ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand

This study explores Thai physicians' rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by 38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians' case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented.     

"Virtual" health care organizations and the challenges of improving quality

This article examines the challenges of improving health care quality continuously within and across "virtual" provider organizations such as independent practice associations and physician-hospital organizations. It draws on recent research and theory about interorganizational networks in other fields to develop recommendations for securing physicians' commitment to quality improvement strategies in today's health care environment.     

Institutional forces in the acceptance of managed care practices by physicians

We evaluated physicians' acceptance of managed care using data from Connecticut physicians. We grouped physicians' attitudinal responses on three dimensions and applied an institutional distance framework to evaluate factors that influence physicians' acceptance of managed care practices. Our results demonstrate the potency of institutional forces in affecting physician attitudes: health care organizations must more effectively integrate their values and beliefs with the physician community. The institutional distance theory evaluated in this article provides new information for policymakers and managers as gaining physician acceptance of certain practices is necessary to ongoing efforts to reform the health care system.     

US physicians' perceptions of the effect of practice guidelines and ability to provide high-quality care

OBJECTIVES: In the USA, health care organizations frequently disseminate practice guidelines to physicians, but physicians often resist implementing guidelines when they perceive no improvements in quality of care will result. Greater involvement with a single health care organization may a inverted exclamation market physicians' perceptions of guidelines. We examined the relationship between the perceived effect of guidelines on practice and perceived quality of care for US primary care physicians (PCPs) and specialists with varying levels of financial involvement with a single managed care organization. METHODS: Data were from the 1996-1997 Community Tracking Study, a nationally representative, cross-sectional survey of 12,528 physicians. Data were adjusted for possible confounders using ordinal logistic regression. RESULTS: Almost half the physicians described a moderate to very large perceived effect of guidelines (46% of PCPs, 46% of specialists). Physicians' financial involvement with a single organization was modest: PCPs received on average 24% of their revenue from their largest contract, while specialists averaged 18%. For specialists, increasing perceived effect of guidelines was associated with increasingly negative perceptions of quality of care [beta= -0.16, 95% confidence interval (-0.22, -0.10)]. Similar results were obtained for PCPs with low levels of financial involvement with a single organization. However, this negative association disappeared for PCPs with higher levels of financial involvement. CONCLUSIONS: PCPs with substantial financial involvement with a single organization who perceive greater effects of guidelines on practice have less negative perceptions of their ability to provide high-quality care. Although our data cannot confirm a causal relationship, financial involvement with a single organization may be one factor linking practice guidelines to high-quality care.     

Liability for managed care decisions: the Employee Retirement Income Security Act (ERISA) and the uneven playing field.

As managed care organizations expand their programs of quality assurance and physician evaluation, more medical malpractice lawsuits may be brought against managed care organizations on the ground that, like hospitals, they are legally responsible for negligent corporate acts that injure patients. However, the federal Employee Retirement Income Security Act (ERISA) shields managed care organizations from liability when they are part of an employee group health plan governed by ERISA. Unlike patients with other types of insurance, patients in ERISA health plans do not have a malpractice remedy for a managed care organization's negligence. A few federal appeals courts recently recognized that ERISA plans can be vicariously liable for their physicians' medical malpractice, but only if the physician is the plan's employee or agent. Yet ERISA still prohibits negligence claims against ERISA health plans for injuries resulting from denial of plan benefits, failure to use qualified physicians, utilization review, or improper plan administration. Current managed care operations do not neatly distinguish between administering benefits and controlling quality of care. Neither should the law. ERISA should be amended to provide employees with the same remedies that patients in non-ERISA plans enjoy.     

Discretionary decision making by primary care physicians and the cost of U.S. Health care

Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.     

Prevention in primary care: variability in physician practice patterns in New York City

We conducted a telephone survey of 120 randomly selected primary care physicians in New York City. This survey, which was completed in October 1984, concerned physicians' recommendations for health promotion and disease prevention. The recommendations by these physicians were often at variance with the recommendations of nationally recognized organizations such as the American Cancer Society and the American College of Physicians. Multivariate analysis revealed that board-certified physicians, U.S. medical graduates, and younger physicians agreed more frequently with the recommendations of national organizations. The physicians surveyed agreed upon the need to include health promotion and disease prevention in their practices. Eighty-seven percent agreed with the statement, "Physicians should probably practice more preventive medicine than they presently do." Reasons given for the failure to practice more prevention included lack of time (70 percent), inadequate reimbursement (60 percent), and "unclear recommendations" (58 percent). Approximately four out of five of the physicians felt a task force was needed to "clarify recommendations" for preventive medicine. The findings of this survey suggest a need for increased physician training and education in disease prevention and health promotion.     

Acceptance and self-reported use of national occupational medicine practice guidelines

The authors conducted a survey to ascertain post-training attitudes and self-reported use of the American College of Occupational and Environmental Medicine occupational medicine practice guidelines. Trainees were surveyed 3 to 4 months after completing a case-based practice ACOEM occupational practice guidelines seminar. Of 96 physician respondents, 95% reported that the guidelines improved their practice in some manner. Fifty-two percent of physicians thought that guideline use decreased medical costs. Seventy-one percent reported that their care complied with the guidelines in 70% or more of their cases; however, "actually considering the guidelines in particular cases" was reported by only 47%. Discussion of cases was frequent (92%) and involved physicians, patients, and other health care providers. We concluded that physicians' attitudes toward the guidelines are positive and that reported compliance is high. Guidelines are discussed frequently.     

Bringing the physician back in: communication predictors of physicians' satisfaction with managed care

Data from a survey of physicians in a west coast city (n = 356) are used to measure physicians' extra-occupational sources of dissatisfaction. Data revealed a significant relationship between physicians' satisfaction and their managed care experience, their communication with managed care organizations, and views of managed care practice. Results suggest that managed care currently plays a large and significant role in predicting physicians' satisfaction. The importance of communication between physicians and managed care organizations is illustrated in the strength of the relationships between communication variables and managed care decisions. Furthermore, in assessing the strength of the relationship, regression analysis reveals that communication with managed care accounts for the largest percentage of variance in physicians' satisfaction. The results of this study suggest that communication with managed care organizations affects physicians' satisfaction with every facet of the organizational environment, including leading physicians who report problematic communication with managed care organizations to say that they would be less likely to choose the same career path again.     

Guías de práctica clínica y atención primaria. Informe SESPAS 2012

Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.     

Clinical practice guidelines and primary care. SESPAS report 2012

Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.     

The effects of gender on primary care physician attitudes and practice orientations

What gender-related differences are there among primary care physicians, and what are the implications of the similarities and differences among male and female physicians for health care reform? This study delineates the similarities and differences between male and female physicians. There is a statistically significant relationship between gender and physicians' ages, years in practice, medical practice organization, practice location, and concerns for professional autonomy and the paperwork demands of an alternative health care plan (AHP). There are no significant gender-related differences in physicians' concerns for reimbursement, support for the ongoing innovations in the health care delivery system, support for government involvement in health care delivery and financing, and in physicians' attitudes toward Medicaid beneficiaries. Although the majority of the female subjects of this study practice in public medical institutions, there are no statistically significant differences in male and female physicians' Medicaid caseloads, and in their participation in a government-sponsored alternative health care delivery plan for Medicaid beneficiaries. The study concludes by exploring the implications of the findings for health care reform.     

Disease Management of Chronic Obstructive Pulmonary Disease from a Disease Management Organization Perspective

Treatment of patients with chronic obstructive pulmonary disease (COPD) demands a great deal of time and technology, which physicians and healthcare systems tend to have in short supply. COPD is the fourth leading cause of death in the US and the disease is severely under-diagnosed. Many physicians report being too rushed to provide optimal care to patients with COPD, and many gaps exist in patient care and physician knowledge.This article examines the methods used by a disease management organization to provide value to patients with COPD, physicians, and payers through innovative information technology (IT) applications and telephonic nurse coaching. The organization encourages patient self-care through regular phone calls from a nurse coach, interactive web and telephone health status reporting, educational materials, and other means. Many patients with COPD need help understanding concepts that may seem obvious to healthcare professionals. By using motivational interviewing techniques, nurse coaches provide emotional support and information on how to monitor and track symptoms in an effort to improve clinical outcomes.The disease management organization works with the physician to support the physician plan of care, while also reinforcing evidence-based medicine and best-practice guidelines. The organization partners with physicians, offering data useful to medical practice without disrupting delivery of care. The disease management organization can assist payers in gaining a population perspective via data mining and predictive modeling. There is a growing body of evidence that disease management organizations can improve patient outcomes in individuals with chronic conditions such as COPD.     

The ethics of managed care. An initial look at physicians' perspectives

The need for medical care in the United States had exceeded the financial resources required to pay for that care. To address this problem, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing ethical pressures. This article reviews the ethical dilemmas physicians face under a managed care system and conducts a national random sample of general practitioners and surgeons regarding four major ethical dilemmas: under treatment of patients due to overt pressures or financial incentives, breaches of patient confidentiality by the physician that are required by the managed care plan, lack of disclosure to the patient of the financial incentives or overt pressures under which the physician functions, and overuse of practice guidelines. The results of this survey suggest that physicians are more likely to compromise patients' confidentiality and not discuss financial arrangements with patients than they are to compromise actual patient care. Those physicians with more than 30 percent of their patient load coming from managed care are more likely to have faced the scenarios presented by the survey. There is, however, no statistically significant difference in the physicians' responses to these scenarios based on the percentage of the physicians' patient load coming from managed care.     

Exploring dual commitment among physician executives in managed care

The growth of a medical management specialty is a significant event associated with managed care. Physician executives are lauded for their potential in bridging the clinical and managerial realms. They also serve as a countervailing force to help the medical profession and patients maintain a strong voice in healthcare decision making at the strategic level. However, little is known about their work loyalties. These attitudes are important to explore because they speak to whose interests physician executives consider and represent in their everyday management roles. If physician executives are to maximize their effectiveness in the healthcare workplace, both physicians and organizations must view them as credible sources of authority. This study examines organizational and professional commitment among a national sample of physician executives employed in managed care settings. Data used for the analysis come from a national survey conducted through the American College of Physician Executives in 1996. The findings support the notion that physician executives can and do express simultaneous loyalty to organizational and professional interests. This dual commitment is related to other work attitudes that contribute to success in the management role. In addition, it appears that situational factors increase the chances for dual commitment. These factors derive from a favorable work environment that includes both organizational and professional socialization in the management role. The results of the study are useful in specifying the training and socialization needs of physicians who wish to do management work. They also provide a rationale for collaboration between healthcare organizations and rank-and-file physicians aimed at cultivating physician executives who are credible leaders within the healthcare system.     

Continuity of care, informed consent, and fiduciary responsibilities in for-profit managed care systems

The replacement of fee-for-service systems by managed care systems offers opportunities for cutting medical costs, integrating health care delivery systems, and improving communication among physicians. Before these benefits can be realized, however, a number of problems must be addressed. First, managed care systems must find ways to foster continuity of care in a market that has thus far proved unstable. Second, managed care systems must find ways to protect the patient's right to fully informed consent even while educating patients about the importance of cost-effectiveness and why certain treatments might not be included in their health plan. Third, managed care systems must find ways to promote physicians' fiduciary responsibilities to patients and to respect physicians' clinical judgments even while creating legitimate incentives to provide cost-effective health care.     

Managed care plans and the organizational arrangements with group practices

This article addresses the variety of structural and legal arrangements between group practices and health plans. The continuum of relationships will be discussed, including long-term arrangements whereby in exchange for long-term commitments to provide physician capacity, providers are given a capital contribution from managed care plans; management services organizations whereby managed care plans create management companies that provide turnkey management services in exchange for capital, with a commitment by the group practices to provide physician services to the health plan over a long period of time; mixed equity relationships where physicians and managed care plans jointly own the group practice, which group practice also has an ownership interest in the managed care plan itself; and acquisition of the group practice by the managed care plan. Each of these structures will be described, along with the legal issues that may be considered in any of these relationships.