Managed care and primary physician satisfaction.
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BACKGROUND: We examined whether physician compensation, financial incentives, and care management tools were associated with primary physician job and referral satisfaction. Our study was guided by a conceptual model of physician satisfaction derived from published evidence. METHODS: A cross-sectional survey was performed of 495 primary physicians (family practitioners, general practitioners, general internists) in the Seattle metropolitan area in 1997. RESULTS: Bivariate analyses revealed that salary compensation, productivity bonuses, and withholds for referrals were associated with job and referral dissatisfaction. However, after controlling for physician, practice, and office characteristics, only the association between salary payment and job dissatisfaction remained significant. Practice in offices with more physicians had the strongest association with physician job dissatisfaction. CONCLUSIONS: Although managed care features are correlated with physician job and referral dissatisfaction, the source of dissatisfaction may originate from being an employed physician in a large medical group with more physicians, which may be more likely to impose bureaucratic controls that limit physician autonomy. (+info)
Assessing the cultures of medical group practices.
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BACKGROUND: The culture of medical group practices is gaining increasing attention as one of the most important organizational factors influencing the costs and quality of health care. Based on organizational theory, we propose that the culture of the practice differs depending on size, ownership, location, and the number of medical specialties. METHODS: A survey was sent to 1223 physicians in 191 clinics in the upper Midwest. The clinic response rate was 77%. The survey instrument identifies 9 culture dimensions, each with 3 to 6 measurement statements. RESULTS: Smaller clinics had higher scores on 6 of the 9 dimensions. Physician-owned clinics had higher scores on 4 of the 9 dimensions, whereas system-owned clinics had a higher score on only 1 dimension. Only 1 dimension differed among the locations. Single-specialty clinics had higher scores on 4 dimensions and multispecialty clinics had higher scores on 2 dimensions. CONCLUSION: Our data confirm the contention that the culture of medical group practices varies considerably; to a degree, this variance is as predicted by organizational theory. The culture changes as group practices become larger and more complex through diversification into multispecialty practices or become part of larger health care systems. (+info)
General practice in Gloucestershire, Avon and Somerset: explaining variations in standards.
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Variations in standards are found in all health services. The method and amount of funding are thought to be important reasons for these variations. A cross sectional survey of all general practices in three counties in south west England was undertaken in order to explain variations in the level of development. A development score for each practice was calculated. There was wide variation in standards as described by the level of development. Multiple regression analysis showed that being a training practice, having a practice manager, the partners having a younger mean age, a larger total number of patients registered with the practice and a lower Jarman underprivileged area score were all independently related to a higher level of practice development. In addition, the responsible family health services authority was also related to the level of development. A combination of professional factors such as the decision to become a training practice, environmental factors such as the family health services authority or the underprivileged area score and economic factors reflected in the total list size determine the level of practice development. The most easily corrected factor is the employment of a practice manager. It is suggested that differences in standards in general practice may be increased rather than decreased by the fundholding scheme. (+info)
Partnership effects in general practice: identification of clustering using intra-class correlation coefficients.
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Although most United Kingdom general practitioners (GPs) work together in a shared professional arrangement termed 'partnership', little is known about the nature of such partnerships. We report the results of a survey of 61 general practice partners in 15 group practices and their attitudes to prescribing and managerial issues related to participation in a commissioning group. Intra-class correlation coefficients (ICCs) were used to explore how these individually held attitudes clustered within groups. The low ICCs found for attitudes relating to prescribing issues suggested that GPs acted individually in this respect, while, in contrast, responses to managerial questions clustered strongly in partnerships, implying that managerial attitudes were more likely to be shared within partnerships. The ICC statistic is a useful tool for exploring homogeneity and heterogeneity within general practice partnerships. (+info)
Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care.
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Evidence from one practice and from the literature suggest that approximately half of most common chronic disorders are undetected, that half of those detected are not treated, and that half of those treated are not controlled: the 'rule of halves'. Workload in primary care would increase by at least 12% if all common and important chronic disorders were fully diagnosed, treated and followed up; the accompanying effects on prescribing costs would be complex, but not necessarily inflationary. The relationship between these data and the new general practitioner contract is discussed. (+info)
Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status.
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BACKGROUND: Barriers to adult immunizations persist as current rates for pneumococcal polysaccharide vaccine (PPV) receipt among eligible adults remain below national goals. This study investigated potential barriers to patients receiving the PPV, including predisposing, enabling, environmental and reinforcing factors among physicians from a variety of practice and geographic settings. METHODS: Participants were 60 primary care physicians from inner-city, rural, suburban, and Veterans Affairs practices, which included adults aged 65 years and older. Elderly patients able to complete a telephone interview were randomly selected from each physician's practice. RESULTS: Self-reported PPV vaccination status was significantly related to physician report of routinely providing PPV to their patients and to the practice providing immunization clinics or other immunization promotion programs. Physicians who were highly unlikely to refer uninsured adults to health departments for immunizations had a significantly higher percentage of patients reporting receipt of PPV (P = .03). CONCLUSIONS: Enabling and environmental factors related to physicians, such as economic and insurance issues, were significant barriers to PPV vaccination. Vaccination rates might be improved through efforts that reduce likelihood of referral for immunizations and office systems that support immunization, such as patient and provider reminders and express vaccination clinics. (+info)
Practice, clinical management, and financial arrangements of practicing generalists.
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OBJECTIVE: To describe the practice settings, financial arrangements, and management strategies experienced by generalist physicians and identify factors associated with reporting pressure to limit referrals, pressure to see more patients, and career dissatisfaction. DESIGN: Cross-sectional mail survey. PARTICIPANTS AND SETTING: Six hundred nineteen generalist physicians (62% response rate) caring for managed care patients in 3 Minnesota health plans during 1999. MEASUREMENTS AND MAIN RESULTS: Twenty-six percent of physicians reported pressure to limit referrals. In adjusted analyses, female physicians and those who were board certified acted as gatekeepers for most of their patients, received incentives based on performance reports and quality profiles, and received direct income from capitation, and were more likely than others to report this pressure (all P <.05). Sixty-two percent reported pressure to see more patients. In adjusted analyses, this pressure was more frequent among physicians in practices owned by health systems, those using physician extenders, and among physicians paid by salary with performance adjustment or those receiving at least some capitation (all P <.05). One-quarter (24%) of physicians were dissatisfied with their career in medicine. In adjusted analyses, physicians reporting pressure to limit referrals (risk ratio, 1.12; 95% confidence interval, 1.01 to 1.19) and those reporting pressure to see more patients (risk ratio, 1.37; 95% confidence interval, 1.08 to 1.66) were more likely to be dissatisfied than other physicians. CONCLUSIONS: Pressures to limit referrals and to see more patients are common, particularly among physicians paid based on productivity or capitation, and they are associated with career dissatisfaction. Whether future changes in practice arrangements or compensation strategies can decrease such physician-reported pressures, and ultimately improve physician satisfaction, will be an important area for future study. (+info)
A controlled trial of an advanced access appointment system in a residency family medicine center.
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BACKGROUND AND OBJECTIVES: The implementation of advanced access appointment systems has improved continuity of care, patient and physician satisfaction, physician productivity, and average physician panel size in private practice and group-model HMO settings. This study's purpose was to document the patient care benefits, practice management benefits, and educational outcomes from the controlled implementation of an advanced access appointment system in a residency family medicine center. METHODS: Two faculty-resident teams were created. One team adopted the advanced access system while the other team continued using a traditional access system. Outcome measures included length of time needed to obtain an appointment (days to third available appointment), continuity (percentage of visits with the patient's designated provider), no-show rates, productivity, visits lost to outside providers, panel sizes, and patient satisfaction. Outcomes were measured at baseline and quarterly for 1 year after initial implementation. RESULTS: After implementation, the "days to third available appointment" for the advanced access group was 5 days, compared to 21 days for the traditional access group. A significant improvement in continuity (ie, a match between the primary care physician and patient) for the advanced access team was found. Comparison of no-show rates between the advanced access and traditional access teams revealed significant between-subjects effect, but controlling for within-subject variation using repeated measures ANOVA eliminated this effect. Advanced access residents increased their continuity above 50% while increasing provider satisfaction with office practice and scope of practice. CONCLUSIONS: Faculty and residents can successfully use advanced access. Advanced access can enhance residency education by reducing appointment delays and significantly increasing the patient-primary care physician match. (+info)