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The Impact of Practice Setting on Physician Perceptions of the Quality of Practice and Patient Care in the Managed Care Era
Eric L. Chehab, BA;
Neethi Panicker, BA;
Philip R. Alper, MD;
Laurence C. Baker, PhD;
Sandra R. Wilson, PhD;
Thomas A. Raffin, MD
Arch Intern Med. 2001;161:202-211.
Background Managed care is practiced in both traditional institutional health maintenance
organization (HMO) settings and in a variety of complex and decentralized
office-based arrangements. This study examines how practice setting affects
physician perceptions of the quality of professional practice and patient
care in a managed care environment.
Participants and Methods A survey was conducted in 1998 of 1081 physicians in San Mateo County,
California, who practice in either a traditional staff group model HMO (SGM-HMO)
(n = 113) or office-based independent practice (OBIP) (n = 250). Respondents
were surveyed about current and past practice characteristics, income changes,
current satisfaction with professional and patient care matters, utility of
treatment guidelines and formularies, and general perceptions of managed care.
Responses were compared between practice settings using bivariate comparisons
and logistic regression analyses.
Results Physicians in the SGM-HMO and those in OBIP reported similar hours worked
per week, time spent with patients during office visits, and total patient
encounters per week. Declining income was more frequent in OBIP (61% vs 47%)
and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO).
Adjusting for income changes, practice setting, years in practice, and sex,
SGM-HMO physicians were significantly more satisfied with a variety of professional
and quality of care issues (P<.001), viewed more
favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions
of managed care (P<.001) than OBIP physicians.
Conclusions In a managed care environment, SGM-HMO physicians are significantly
more satisfied with the quality of practice and patient care than physicians
in OBIP. This study suggests that the myriad managed care contracts, formularies,
and guidelines received by physicians in OBIPs may lead to more negative perceptions
of the quality of professional practice and patient care.
From the Departments of Medicine (Mr Chehab, Ms Panicker, and Drs Wilson
and Raffin), Health Research and Policy (Drs Baker and Wilson), and Center
for Biomedical Ethics (Drs Alper and Raffin), Stanford University School of
Medicine, Stanford, Calif; Department of Medicine, University of California
at San Francisco (Dr Alper); Palo Alto Medical Foundation, Research Institute,
Palo Alto, Calif (Dr Wilson); and San Mateo County Medical Association, San
Mateo, Calif (Dr Alper).
Corresponding author and reprints: Thomas A. Raffin, MD, Division
of Pulmonary and Critical Care Medicine, Center for Biomedical Ethics, Room
H3151, Stanford University School of Medicine, Stanford, CA 94305-5236.
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