THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 - PDF document

THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 PHYSICIAN SATISFACTIONEvolving Dissatisfaction Among Primary Care PhysiciansBruce E. Landon, MD, MBA; Robert Aseltine, Jr, PhD; James A. Shaul, MHA; ael Miller, MBA; Bruce A. Auerbach, MD; and Paul D. Cleary, PhDincreasingly subjected to profiling, utilization review,those in many other countries, and medicine is stillthose that have been expressed previously.examine trends in career satisfaction amongphysicians working with managed care plans.Cross-sectional surveys conducted in 1996surveyed primary carephysicians (PCPs) affiliated with 5 large health plans inMassachusetts and assessed physiciansÕ ratings of overall sat-isfaction with their current practice situation and with man-survey and 966 (42%) responded to the 1999 survey. In 1996,19.8% of physicians were somewhat or very dissatisfied withtheir current practice situation vs 33.4% in 1999, an increase)erall dissatisfaction with man-tivariable models, external influences on physiciansÕ practiceswere important predictors of overall dissatisfaction. Physicianshose choice of hospitals was restricted (odds ratio, 2.23; 95%confidence interval, 1.30-3.78) and those who reported thatmanaged care plans influenced their practice Òa lotÓ (oddsatio, 1.85; 95% confidence interval, 1.10-3.11) were morelikely to be dissatisfied. Adequacy of reimbursement was animportant predictor of overall satisfaction and satisfaction withmanaged care, and ways physicians experienced financialincentives were associated with managed care dissatisfaction. Primary care physicians in Massachusetts areincreasingly dissatisfied with their practice and with

managedcare. Continued erosion of physician satisfaction could havethe workforce attracted to medicine as a career. rom the Department of Health Care Policy, Harvard MedicalSchool (BEL, JAS, PDC); the Division of General Medicine andPrimary Care, Beth Israel Deaconess Medical Center (BEL); theDepartment of Sociology, Boston University (RA); and theMassachusetts Medical Society (YM, BAA), Boston.his work was supported by the Massachusetts Medical Society,Address correspondence to: Bruce E. Landon, MD, MBA, theDepartment of Health Care Policy, Harvard Medical School, 180Longwood Avenue, Boston, MA 02115. E-mail: landon@hcp.med.harvard.edu. VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE fession or not to encourage others to enter.country.ity of care, be very expensive, and cause a great dealciency and quality of care negatively, they areoverall career satisfaction, few have systematicallytracked changes in satisfaction over time. We areare now several years old, and the third study, alsocare changing over time? Second, what features of physicianÕs practice situation, attitudes, and experi-described in detail elsewhere.HMOs in Massachusetts. Collectively, these healthhave been described fully elsewhere,ing section. For the 1999 survey, we shortened andMeasuresdissatisfied.Ó They were then asked whether theywould recommend working with the target health planto physician colleagues and whether they would rec-ommend insurance coverage from the target healthplan to a member of their family using a 5-point scaleIn the 1999 survey, physicians were also asked to rate Dissatisfaction Among Primary Physicians THE AMERICAN JOURNAL OF

MANAGED CAREOCTOBER 2002 the quality of care and the burden of treating patientsgraduation from medical school, primary area ofbursement and referral policies of their practice.covered by their current health plan.Ó We also askedor Òfee-for-service medicine influences physicians towhat percentage of their income from clinical prac-year. We then asked physicians what percentages oftheir clinical income were derived from fee-for-ser-bonus payments, we asked whether their personalincome is adjusted up or down based on their person-of their group and, if so, the percentage of their per-sonal income in the previous year that was earned inthe form of a bonus, returned withhold, or surplus pay-determined adjustments to their personal income.Last, we asked for what percentage of their patient vis-The surveyprofessional autonomy, adequacy of the fee schedulepaperwork and of appealing denied claims, supportStudy ProceduresFor both rounds of the survey, self-administeredreturn the questionnaire. For the second survey, ato participate in the survey, and nonrespondentsuing medical education program was offered as anby target plan, age, sex, and specialty using admin-istrative data from the Massachusetts Board ofRegistration of Medicine. We used the Student physicianÕs main or other practice influenced care Òa PHYSICIAN SATISFACTION influenced care Òa lot.Ó Finally, we created 2 com-test for continuous variables. We estimated multi-Cross-sectional Analysis.analyzed the 1999 data tocare. We assessed the associa-physician dissatisfaction usingmodels to assess the indepen-measures. To simplify the pre-sentation of the models, wewith other vari

ables in the RESULTS). For the 1999 survey, 28% ofof the sample graduating at least 10 years earlier. VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE Characteristics of Respondents to the 1996 and 1999 Surveys ofMassachusetts PCPs 1996 Survey1999 Survey(n = 1336)(n = 966)emale, %25.928.4ime since medical school graduation, mean, y22.422.7ime since medical school graduation, %0-10 y11.29.1�10 y88.890.9Specialty, %amily medicine15.414.2General medicine49.051.9General pediatrics27.727.7Specialists who are PCPs8.06.3Practice type, %Solo21.124.6Single specialty39.438.0Multispecialty39.537.4ime spent in patient care, mean, h/wk46.146.9atient visits per week, mean, No.96.395.2atients in any managed care plan, %*0%-25%7.35.826%-50%30.724.151%-75%41.438.576%-100%20.631.6 PCPs indicates primary care practitioners. Dissatisfaction Among Primary Physicians THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 50%(). Similarly, overalldissatisfaction with managedincreased from 28.3% into 62.1% in 1999(()the odds of being dissatisfiedwith managed care was 4.18(95% CI, 3.37-5.19).Similar trends were evidentin other global assessments ofmanaged care. Many fewerit was somewhat or much bet-ter. Similarly, the burdenofor much better.Predictors of Satisfactionith Current Practiceand Satisfaction With Managed Care in 1999 Changes in Physician Satisfaction Between the 1996 and 1999Surveys of Massachusetts PCPs 1996 Survey1999 Survey(n = 1336)(n = 966)Strongly agree28.412.4Agree47.249.7Undecided14.322.4Disagree7.511.7Strongly disagree2.63.8Strongly agree27.614.3Agree44.147.8Undecided14.519.0Disagree9.613.4Strongly disagree4.25.5Overall satisf

action with current practice situation, %*ery satisfied29.717.7Generally or somewhat satisfied50.648.9Somewhat or generally dissatisfied16.025.7ery dissatisfied3.77.7Overall satisfaction with managed care, %*ery satisfied6.04.8Generally satisfied41.233.0Neither satisfied nor dissatisfied24.6ÑSomewhat or generally dissatisfied22.742.0ery dissatisfied5.620.1Much betterNA2.3Somewhat betterNA14.4About the sameNA47.5Somewhat worseNA30.0Much worseNA5.9Much betterNA0.9Somewhat betterNA5.2About the sameNA24.7Somewhat worseNA45.0Much worseNA24.2 PCPs indicates primary care practitioners; NA, not applicable.he exact wording was Ògenerally dissatisfiedÓ in 1996 and Òsomewhat dissatisfiedÓ in 1999. est for difference between 1996 based on the percentage Òsomewhat/generally and very dis-ÒNeither satisfied nor dissatisfiedÓ was not present as a response option for the 1999 survey. PHYSICIAN SATISFACTION VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE dissatisfied with theiracteristics were signifi-current practice and dis-physicians who ratedas current practice. Conversely, physicians in largerMultivariable Predictors of Overall Dissatisfactionith Their Current Practice Situation andDissatisfaction With Managed Care in 1999of overall dis-Tabldissatisfied. In addition, external influences on95% CI, 1.30-3.78) and Changes in Physician Satisfaction Between the 1996 and 1999 Surveysof Massachusetts Primary Care Physicians Dissatisfaction WithManaged Care in GeneralDissatisfaction WithOverall Practice SituationSomewhat or Very Dissatisfied, % Changes in Physician Health Plan Recommendations Between the1996 and 1999 Surveys of Massachusetts P

rimary Care Physicians a Physician a Family Memberor FriendPhysicians Who Disagree or Strongly Disagree That ey Would Recommend the Target Health Plan, % Dissatisfaction Among Primary Physicians THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 0.25-0.75). Physicians whorated the adequacy of reim-care differed from the predic-tracts, personal and practicetor (OR, 1.52; 95% CI,1.07-2.17). Finally, whereasment was also an importantfactors. Physicians in largerrisk pools in which financialcare (OR, 0.52; 95% CI, 0.30-0.92), whereas thosewho Physician and Practice Characteristics and PhysicianDissatisfactionÑ1999 Survey of Massachusetts PCPs Proportion Somewhat or VeryProportionDissatisfiedSampleCurrent PracticeManaged Careersonal and Practice Characteristics71.672.971.828.427.128.2ime since medical school graduation, y*0-109.15.67.6�1090.994.492.5amily medicine14.210.211.5General medicine51.959.554.1General pediatrics27.720.927.3Specialists who are PCPs6.39.57.1Practice type*Solo24.626.726.9Single specialty38.034.439.5Multispecialty37.438.933.70-4042.735.040.241-5025.226.024.751-6019.821.420.46112.417.614.70-255.86.76.426-5024.125.925.551-7538.535.439.576-10031.632.028.6Managed care contracts, No.0-424.019.817.95-948.050.753.31028.029.528.8Practice affiliationIDS38.141.639.7IPA or PHO43.040.543.9None19.017.916.4 PHYSICIAN SATISFACTION PCPs indicates primary care physicians; IDS, integrated delivery system; IPA, independentpractice association; PHO, physician hospital organization.ho are very or somewhat dissatisfied withmanaged care and those who are not.ho are very or somewhat dissatisfied withmanaged care and those who

are not.ho are very or somewhat dissatisfied withmanaged care and those who are not.Physicians in an IDS can also be members of an IPA or PHO. ÒNoneÓ refers to physiciansho are not in an IPA, PHO, or IDS. (continued on following page) VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE Sensitivity Analysisreceived in the 1999 sur-achieved in 1996. We Physicians in all types of Physician and Practice Characteristics and Physician DissatisfactionÑ1999 Survey of Massachusetts PCPs Proportion Somewhat or VeryProportionDissatisfiedSampleCurrent PracticeManaged CareInfluences on PracticeMedical group, IPA, or PHO restricts No49.737.547.950.362.552.1Medical group, IPA, or PHO restricts No40.827.338.659.272.861.4Amount of influence on group **referral policiesAny69.362.866.0None30.737.234.0Any52.640.249.3None47.459.850.7Medical groups influence the way care is providedNone to some54.457.256.5A lot45.642.843.5Other physician organizations influence *the way care is providedNone to some78.374.075.7A lot21.726.024.3Managed care plans influence the way care is providedNone to some78.771.276.5A lot21.328.823.5ailability of subspecialists for referralsGood to excellent87.380.982.2air or poor12.719.217.8Ability to exercise independent Good to excellent90.882.986.4air or poor9.217.113.6 PCPs indicates primary care physicians; IDS, integrated delivery system; IPA, independent practiceassociation; PHO, physician hospital organization.ho are very or somewhat dissatisfied with man-aged care and those who are not.ho are very or somewhat dissatisfied with man-aged care and those who are not.ho are very or somewhat dissatisfied with man-aged care a

nd those who are not.Physicians in an IDS can also be members of an IPA or PHO. ÒNoneÓ refers to physicians who arenot in an IPA, PHO, or IDS. (continued on following page) Dissatisfaction Among Primary Physicians THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 from 1995 or 1996,reports. In California,perceived level of auton-also declined markedly.rent practice in 1995.InSurvey of Young Physi-addition to personal char-acteristics such as yearsin practice and specialty,most strongly related toence physiciansÕ prac- Physician and Practice Characteristics and Physician DissatisfactionÑ1999 Survey of Massachusetts PCPs Proportion Somewhat or VeryProportionDissatisfiedSampleCurrent PracticeManaged Careinancial Factors and ÒHasslesÓPrimary payment typeSalary37.836.836.6ee for service26.826.728.3Mixed27.330.827.2Capitated4.93.64.5Other3.22.23.4ersonal performance affects income*71.375.073.9No28.725.126.1Practice performance affects income59.161.660.7No40.938.439.3No86.886.889.613.213.210.4Not paid on time*Never to twice68.763.060.6Several times or regularly31.337.039.4Denied paymentNever to twice71.967.264.2Several times or regularly28.132.835.9ee schedule or capitation rateGood to excellent52.641.041.6air or poor47.458.958.4Information given to enrollees about benefits and referralsGood to excellent60.848.252.3air or poor39.251.847.7Ease of obtaining referral authorizations, completing paperwork, and appealing Good to excellent83.976.277.6air or poor16.123.822.4 PCPs indicates primary care physicians; IDS, integrated delivery system; IPA, independent practiceassociation; PHO, physician hospital organization.ho are very or somewh

at dissatisfied with man-aged care and those who are not.ho are very or somewhat dissatisfied with man-aged care and those who are not.ho are very or somewhat dissatisfied with man-aged care and those who are not.Physicians in an IDS can also be members of an IPA or PHO. ÒNoneÓ refers to physicians who arenot in an IPA, PHO, or IDS. PHYSICIAN SATISFACTION VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE aged care, however,seemsto be bers of contracts andThe adequacy of thewith managed care, andmanaged care, physicianthat study, satisfactionphysicians. As in ourstudy, physicians with an Adjusted Predictors of Dissatisfaction With Managed Care and PracticeSatisfactionÑ1999 Survey of Massachusetts PCPs* Somewhat or Very DissatisfiedCurrent PracticeManaged Careersonal and Practice Characteristicsemale (vs male)1.19 (0.75-1.90)0.99 (0.61-1.63)Medical school gr�aduation 10 y (vs 10 y)2.01 (1.02-3.96)Specialty (vs general medicine)amily medicine0.50 (0.27-0.92)Specialists who primarily work as PCPs2.65 (1.11-6.33)General pediatrics0.56 (0.33-0.95)Practice type (vs solo)Single specialty2.26 (0.83-6.12)0.86 (0.35-2.13)Multispecialty1.81 (0.66-5.00)0.70 (0.28-1.75)41-501.03 (0.62-1.71)0.69 (0.42-1.13)51-600.80 (0.47-1.37)0.56 (0.34-0.95)611.68 (0.89-3.17)1.35 (0.64-2.88)26-500.89 (0.29-2.72)0.64 (0.23-1.80)51-750.74 (0.24-2.21)0.62 (0.22-1.70)76-1000.87 (0.29-2.62)0.71 (0.25-2.08)Managed care contracts, No. (vs 0-4)5-91.59 (0.93-2.73)2.19 (1.26-3.80)101.78 (0.99-3.21)2.15 (1.17-3.98)art of an integrated delivery system (vs not)0.73 (0.40-1.35)0.70 (0.38-1.29)rt of a PHO or IPA only (vs not)0.71 (0.40-1.27)0.71 (0.39-1.31)Influe

nces on Practice and AutonomyRating of ability to exercise independent 1.13 (0.87-1.47)1.35 (0.82-2.22)Medical group, IPA, or PHO restricts choice 1.10 (0.65-1.86)0.90 (0.53-1.53)Medical group, IPA, or PHO restricts choice 2.23 (1.30-3.78)Any influence on group referral policies 1.07 (0.40-2.89)0.82 (0.36-2.07)Medical groups influence the way care is 0.87 (0.57-1.33)0.89 (0.59-1.34)provided Òa lotÓ(vs not at all)Any influence on group reimbursement 0.44 (0.25-0.75)Other physician organizations influence the0.77 (0.45-1.33)1.66 (0.99-2.75)y care is provided Òa lotÓ (vs not at all)Managed care plans influence the way care 1.85 (1.10-3.11)is provided Òa lotÓ (vs not at all)1.09 (0.78-1.52)1.52 (1.07-2.17)ersonal performance affects income (vs not)1.17 (0.75-1.84)2.14 (1.39-3.30)50 (vs )0.80 (0.43-1.48)0.52 (0.30-0.92)Denied payment (vs never to twice)1.30 (0.80-2.35)1.65 (1.02-2.67)1.14 (0.80-1.62)1.07 (0.93-1.83)Rating of the fee schedule or capitation rate1.40 (1.04-1.87)Rating of adequacy of benefit information 1.21 (0.96-1.52)1.17 (0.94-1.45)given to enrollees PCPs indicates primary care physicians; PHO, physician hospital organization; IPA, independentpractice association.*Data are given as odds ratios (95% confidence intervals).Includes availability of behavioral health services and of other subspecialists for referrals.Combination of ease of obtaining referral authorizations, completing paperwork, and appealing Dissatisfaction Among Primary Physicians THE AMERICAN JOURNAL OF MANAGED CAREOCTOBER 2002 is thus experienced inmorevey. For a variety of reasons, including increasedachieve good response rates to physician surveys

.In addition, we were unable to offer monetaryresponse rates in other physician surveys. Despitethe low response rate, however, the characteristicsof the representative cross section in 1996 werethat the samples were similar. More important,whereas one can speculate whether dissatisfiedrespond out of frustration with managed care andSecond, we were unable to explore the conse-quences of career dissatisfaction, such as earlythey will be perceived as hassles and will lead to dis-reason for grave concern. Our results are especiallydominated by not-for-profit health plans that consis-the entire country.career. Efforts are needed to develop new strategiesManaged Care and Subcommittee on the Managed CareCosenza, PhD, and Floyd J. Fowler, PhD, for their helptesting; Thomas V. Williams for his instrumental role RESULTSHow good is the qualityMilbank Q.erspectives on organizationalange in the US medical care sector. Annu Rev Sociol.e organization of medical care services: Toward anintegrated theoretical model. Med Care Rev.5. Landon BE, Wilson IB, Cleary PD. A conceptual model of theeffects of health care organizations on the quality of medical care.6. Wilkes MS, Bell RA, Kravitz RL.tion drug advertising: Trends, impact, and implications. Health Aff.olution:How the Web Helps Americans Take Better Care ofThemselves.ashington, DC: Pew Internet & American LifeProject;2000.Managed careÕs role in shaping the physician job9. Warren MG, Weitz R, Kulis S.e impact of managed care onphysicians. Health Care Manage Rev.10. Kassirer JP. PHYSICIAN SATISFACTION VOL. 8, NO. 10THE AMERICAN JOURNAL OF MANAGED CARE 1. Murray A, Montgomery JE, Chang H, Rog

ers WH, Inui T,Doctor discontent: A comparison of physician satisfac-tion in different delivery system settings, 1986 and 1997. On the professional regulation of change. v Monogr.Exit,Voice,and Loyalty.Harvard University Press; 1970.14. Barnard A, Tong K.he doctor is outÑmore and more physi-cians, frustrated with managed care, are trying new professionsHer job now is to help others do what she didÑ16. Buchbinder SB, Wilson M, Melick CF, Powe NR.physician job satisfaction and turnover. PhysiciansÕ perceptions of autonomyHealth Aff.The InterStudy Competitive Edge.9.2.St Paul, MN: InterStudy19. Williams TV, Zaslavsky AM, Cleary PD.Physician experienceswith, and ratings of, managed care organizations in Massachusetts.20. Zaslavsky AM, Williams TV, Cleary PD. erlapping domains in a physician survey with a limited popula-Stat Med.marketplace: PhysiciansÕ views. Health Aff.Effects of HMO market penetration onphysiciansÕ work effort and satisfaction. Health Aff.Community TrackingStudy Physician Survey Public Use File UserÕs Guide. Round One,Release 1. Washington, DC: Center for Studying Health System24. Grumbach K, Osmond D, Vranizan K, Jaffe D, Bindman AB.Primary care physiciansÕ experience of financial incentives in man-25. Linn LS, Davies AR, Fink A, Kosekoff J.Physician and patientcine group practices. 26. Haas JS, Cleary PD, Puopolo AL, Burstin HR, Cook EF,Brennan TA, for the Ambulatory Medicine Quality Improvementgeneral internists in academically affiliated practices in the greater-National Committee for Quality Assurance web site. Availableat: http://hprc.ncqa.org/index.asp. Accessed May 17, 2002. Dissatisfaction Among Primary