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Managed Care/Market Forces

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Being a salaried physician in a large office may be the chief source of physician dissatisfaction with managed care

As managed care and market competition grew in the 1990s, many primary care physicians shifted, sometimes reluctantly, from solo to group practice and from being owners to being salaried employees. Compared with solo practice, large medical groups are more likely to be bureaucratic and to impose controls on the clinic and workload autonomy of their physician employees.

According to a recent study, physician dissatisfaction with managed care may originate from the loss of autonomy associated with being an employed physician in a large medical group with other physicians. The study was supported by the Agency for Healthcare Research and Quality (HS11712) and led by David Grembowski, Ph.D., of the University of Washington.

Dr. Grembowski and colleagues surveyed 495 primary care physicians in the Seattle area in 1997, which at the time had a relatively balanced mix of health maintenance organization, point-of-service, preferred provider organization, and fee-for-service health plans. They examined the impact of physician characteristics; medical office and physician practice characteristics (for example, solo or multispecialty group practice, number of physicians in the office, and physician workload); physician compensation (salary or fee-for-service); financial incentives (for example, productivity bonus and financial withhold for referrals); and care management tools (for example, clinical guidelines or required approval for specialist referrals) on physician job and referral satisfaction.

After controlling for all of these factors, being a salaried employee was significantly associated with physician dissatisfaction, while fewer administrative hours, fewer physicians in the office, and ease of referral were associated with greater job satisfaction. Practices in offices with more physicians had the strongest association with physician job dissatisfaction. Only two characteristics, ease of referral and greater tolerance for uncertainty, were associated consistently with greater referral satisfaction.

See "Managed care and primary physician satisfaction," by Dr. Grembowski, Cornelia M. Ulrich, Ph.D., David Paschane, M.S. and others, in the September 2003 Journal of the American Board of Family Practice 16, pp. 383-393.

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