Community Tracking Study Physician Survey Research Articles

Billing Codes Determine Lower Physician Income for Primary Care and Non-Procedural Specialties.

The income gap between specialists and primary care physicians and among specialists is well established, but the drivers of this difference are not well delineated. Using the Community Tracking Study (CTS) Physician Survey, we sought to isolate and compare premiums paid to physicians for specialization and the proportion of time spent on offices visit rather than procedures. We divided medical subspecialties according the proportion of Medicare billing for Evaluation and Management (E&M) codes for the specialty as a whole. We report substantial differences in income across physician specialty, and over 70 percent of the difference in income remained controlling for factors that may confound the relationship between income and specialty including gender, location and type of practice, and hours. We note a large variation in premiums for specialization: 11.3-46.8 percent above family medicine after controlling for confounders. Classifying medical subspecialties by E&M billing as procedural versus non-procedural specialties revealed clear income differences. Controlling for confounders, procedural medical specialties earned 37.5 percent more than family medicine, as compared with 15.3 percent for non-procedural medical specialties. This analysis suggests that differences in physician income and resulting incentives are a direct consequence of the payment structure itself, rather than compensation for additional years of training or a reflection of different underlying demographics.

Exploration of Leisure Time Valuation to Explain Sex-Based Wage Gaps among Salaried Primary Care Physicians in the US

In the US, female physicians have lower hourly incomes than their male counterparts, across specialties and after adjusting for physician and practice characteristics; however, female physicians work fewer hours than their male counterparts. We wanted to determine whether a simple method of valuing leisure time - overtime pay - might help explain sex-based wage gaps among US primary care physicians. Therefore, we used Community Tracking Study Physician Survey data from 1996-2005 to model the impact of overtime pay on sex-based wage gaps. As overtime premiums increased in our models, sex-based wage disparities decreased: they become statistically insignificant when overtime wages reached 0%, 32%, and 61% premiums using the ordinary least squared model and with 0%, 62%, and 55% premiums using the propensity score weighted model, for internal medicine, family practice, and pediatric physicians, respectively. We conclude that modest overtime premiums reduced sex-based hourly wage gaps for the salaried primary care physicians we examined. Future analyses of sex-based wage gaps should account for leisure time and its trade for work hours when it becomes scarce.

Higher Practice Intensity Is Associated with Higher Quality of Care but More Avoidable Admissions for Medicare Beneficiaries

The relationship between practice intensity and the quality and outcomes of care has not been studied. To examine the relationship between primary care physicians' costliness both for defined episodes of care and for defined patients and the quality and outcomes of care delivered to Medicare beneficiaries. Cross sectional analysis of physician survey data linked to Medicare claims. Physician costliness measures were calculated by comparing the episode specific and overall costs of care for their patients with the care delivered by other physicians. We studied physicians participating in the 2004-2005 Community Tracking Study Physician Survey linked with administrative claims from the Medicare program for the years 2004-2006. Proportion of eligible beneficiaries receiving each of seven preventive services and rates of preventable admissions for acute and chronic conditions. The 2,211 primary care physician respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Patients treated by more costly physicians (whether measured by the overall costliness index or the episode-level index) were more likely to receive recommended preventive services, but were also more likely to experience preventable admissions. For instance, physicians in the lowest quartile of costliness performed appropriate monitoring for hemoglobin A1C for diabetics 72.8% of the time, as compared with 81.9% for physicians in the highest quartile of costliness (p < 0.01). In contrast, patients treated by the physicians in the lowest quartile of episode costliness were admitted at a rate of 1.8/100 for both acute and chronic Prevention Quality Indicators (PQIs), as compared with 2.9/100 for both acute and chronic PQIs for those treated by physicians in the highest quartile of costliness (p < 0.001). Physician practice patterns are associated with the quality of preventive services delivered to Medicare patients. Ongoing efforts to influence physician practice patterns may have differential effects on different aspects of quality.

Physicians' perceptions of autonomy across practice types: Is autonomy in solo practice a myth?

Physicians in the United States are now less likely to practice in smaller, more traditional, solo practices, and more likely to practice in larger group practices. Though older theory predicts conflict between bureaucracy and professional autonomy, studies have shown that professions in general, and physicians in particular, have adapted to organizational constraints. However, much work remains in clarifying the nature of this relationship and how exactly physicians have adapted to various organizational settings. To this end, the present study examines physicians' autonomy experiences in different decision types between organization sizes. Specifically, I ask: In what kinds of decisions do doctors perceive autonomous control? How does this vary by organizational size? Using stacked “spell” data constructed from the Community Tracking Study (CTS) Physician Survey (1996–2005) (n = 16,519) I examine how physicians' perceptions of autonomy vary between solo/two physician practices, small group practices with three to ten physicians, and large practices with ten or more physicians, in two kinds of decisions: logistic-based and knowledge-based decisions. Capitalizing on the longitudinal nature of the data I estimate how changes in practice size are associated with perceptions of autonomy, accounting for previous reports of autonomy. I also test whether managed care involvement, practice ownership, and salaried employment help explain part of this relationship. I find that while physicians practicing in larger group practices reported lower levels of autonomy in logistic-based decisions, physicians in solo/two physician practices reported lower levels of autonomy in knowledge-based decisions. Managed care involvement and ownership explain some, but not all, of the associations. These findings suggest that professional adaptation to various organizational settings can lead to varying levels of perceived autonomy across different kinds of decisions.

Impact of Changes in Medicaid Coverage on Physician Provision of Safety Net Care

The Patient Protection and Affordable Care Act will expand Medicaid coverage substantially, with the goal of improving the health of low-income individuals and reducing disparities in coverage and access. Whether insurance expansions are successful in achieving this goal will depend in part on physician response to changes in insurance coverage mix and the effect of this response on access to care for low-income safety net populations. The objective of the study was to consider the impact of changes in market-level Medicaid coverage on measures of physician participation in care for safety net populations. We use 4 waves of the Community Tracking Study Physician Survey from 1996 to 2005. We estimate both market-level and physician-level fixed effects models, to consider changes in market-level Medicaid rates on measures of physician acceptance of new patients (both Medicaid patients and uninsured patients unable to pay), revenue from Medicaid, and provision of charity care. We also stratify the sample to investigate whether effects differ among office-based versus facility-based physicians. Increases in Medicaid coverage are associated with statistically significant decreases in the likelihood that physicians will accept new uninsured patients who are unable to pay, particularly among office-based physicians. Increases in Medicaid coverage are not associated with changes in acceptance of new Medicaid patients. Past changes in Medicaid coverage rates are not associated with changes in physician acceptance of new Medicaid patients or provision of charity care, although they are associated with lower acceptance of new uninsured patients, particularly among office-based physicians.

The impact of managed care contracting on physicians.

Prior literature suggests that the fragmented U.S. health care system places a large administrative burden on physicians. Less is known about how this burden varies with physician contracting practices. To assess the extent to which physician practice outcomes vary with the number of managed care contracts held or the availability of such contracts. We perform secondary data analyses of the first four rounds of the nationally representative Community Tracking Study Physician Survey (1996-2005), which includes 36,340 physicians (21,567 PCPs [primary care physicians] and 14,773 specialists) across the four survey periods. Our measures include reported hours in patient care, share of hours outside patient care, adequacy of time with patients, career satisfaction, and income. Doctors who contract with more plans report spending more time in patient care (per 11 additional contracts, about 30min per week for PCPs and 20min per week for specialists), report spending a modestly larger share of their time outside patient care (per 11 additional contracts, about 10min per week for PCPs and specialists), are slightly more likely to report inadequate time with patients (odds ratio 1.005 per additional contract for PCPs), and earn higher incomes (per 11 additional contracts, about 3% more per year for specialists). Contracting opportunities confer significant benefits on physicians, although they do add modest costs in terms of time spent outside patient care and lower adequacy of time with patients. Simplifications that reduce the administrative burden of contracting may improve care by optimizing allocation of physician effort.

Do Early Career Indicators of Clinical Skill Predict Subsequent Career Outcomes and Practice Characteristics for General Internists?

To study relationships between clinical skill measures assessed at the beginning of general internists' careers and their career outcomes and practice characteristics. General Internist Community Tracking Study Physician Survey respondents (2000-2001, 2004-2005) linked with residency program evaluations and American Board of Internal Medicine board certification examination score records; n = 2,331. Cross-sectional regressions of career outcome and practice characteristic measures on board examination scores/success, residency evaluations interacted with residency type, and potential confounding variables. Failure to achieve board certification was associated with $27,206 (18 percent, p < .05) less income and 14.9 percent more minority patients relative to physicians scoring in the bottom quartile on their initial examination who eventually became certified (p < .01). Other skill measures were not associated with income. Scoring in the top rather than bottom quartile on the board certification examination was associated with 9 percent increased likelihood of reporting high career satisfaction (p < .05). Among physicians trained in community hospital residency programs, lower evaluations were associated with 14.5 percent higher share of minority patients (p < .05). Both skill measures were associated with practice type. There are associations between early career skill measures and career outcomes. In addition, minority patients are more likely to be treated by physicians with lower early career clinical skills measures than nonminority patients.

Physician-Targeted Financial Incentives and Primary Care Physicians’ Self-Reported Ability to Provide High-Quality Primary Care

High-quality primary care is envisaged as the centerpiece of the emerging health care delivery system under the Affordable Care Act. Reengineering the US health care system into a primary care-driven model will require widespread, rapid changes in the management and organization of primary care physicians (PCPs). Financial incentives to influence physician behavior have been attempted with various approaches, without empirical evidence of their effectiveness in improving care quality. This study examines the above research question adjusting for the patient-centeredness of the practice climate, a major contextual factor affecting PCPs' ability to provide high-quality care. Secondary data on a sample of salaried PCPs (n = 1733) from the nation-wide Community Tracking Study Physician Survey 2004-2005 were subject to generalized multinomial logit modeling to examine associations between financial incentives and PCPs' self-reported ability to provide quality care. After adjusting for patient-centered medical home (PCMH)-consistent practice environment, financial incentive aligned with care quality/care content is positively associated with PCPs' ability to provide high-quality care. An encouraging finding was that financial incentives aligned with clinic productivity/profitability do not to impede high-quality care in a PCMH practice environment. Financial incentives targeted to care quality or content indicators may facilitate rapid transformation of the health system to a primary care-driven system. The study provides empirical evidence of the utility of practically deployable financial incentives to facilitate high-quality primary care.

The Relationship between Physician Compensation Strategies and the Intensity of Care Delivered to Medicare Beneficiaries

To examine the relationship between primary care physicians' (PCPs) payment arrangements and the total costs and intensity of care for specific episodes of care for Medicare beneficiaries. We combined data from the 2004 to 2005 Community Tracking Study Physician Survey on PCP compensation methods with administrative data from the Medicare program for beneficiaries to whom these physicians provided services over the time period 2004-2006. Cross-sectional analysis of physician survey data linked to Medicare claims. The 2,211 PCP respondents included 937 internists and 1,274 family or general physicians who were linked to more than 250,000 Medicare enrollees. Most physicians (62 percent) had been in practice for 11 or more years and 87 percent were board certified. The total spending models show that for both employed physicians and owners, those in highly capitated practice environments had the lowest risk adjusted spending per beneficiary, whereas those receiving just productivity payments had the highest spending. These physicians also had lower intensity of care for episodes of care. Physicians in highly capitated practices had the lowest total costs and intensity of care, suggesting that these physicians develop an overall approach to care that also applies to their FFS patients.

Does Patient Use of Medical Information Affect Physician Practice Incentives to Provide Care?

Abstract Patients as consumers are assuming a more active role in their medical care decision-making, which has been prompted by better access to medical information. Patient use of medical information may affect physician practice incentives to provide care, which critically depends on the agency relationship between physician and patient. If patient use of medical information improves communication and understanding, physicians may need to spend less time explaining what treatments are needed and convincing patients about the appropriateness of their recommendations, increasing incentives to provide care. If patients use information to demand treatments and procedures that are at odds with what the physician would recommend, this might lead to a contentious relationship, making it more difficult to agree upon any course of treatment. We use the Community Tracking Study (CTS) physician survey data, a nationally representative sample in the United States, to study the effects of more-informed patients on physician incentives to provide care. We estimate ordinary least squares and ordered probit models, and apply instrumental variables method to correct for the potential endogeneity of the measure of more-informed patients. The empirical results indicate that more-informed patients appear to be reducing physician incentives to provide care. This is consistent with the view that patient use of medical information from alternative sources besides their own physician may be interfering with the physician’s ability to provide care.

Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries.

To identify factors associated with the cost of treating high-cost Medicare beneficiaries. A national sample of 1.6 million elderly, Medicare beneficiaries linked to 2004-2005 Community Tracking Study Physician Survey respondents and local market data from secondary sources. Using 12 months of claims data from 2005 to 2006, the sample was divided into predicted high-cost (top quartile) and lower cost beneficiaries using a risk-adjustment model. For each group, total annual standardized costs of care were regressed on beneficiary, usual source of care physician, practice, and market characteristics. Among high-cost beneficiaries, health was the predominant predictor of costs, with most physician and practice and many market factors (including provider supply) insignificant or weakly related to cost. Beneficiaries whose usual physician was a medical specialist or reported inadequate office visit time, medical specialist supply, provider for-profit status, care fragmentation, and Medicare fees were associated with higher costs. Health reform policies currently envisioned to improve care and lower costs may have small effects on high-cost patients who consume most resources. Instead, developing interventions tailored to improve care and lowering cost for specific types of complex and costly patients may hold greater potential for "bending the cost curve."

Time is money: opportunity cost and physicians' provision of charity care 1996-2005.

To test whether physicians' provision of charity care depends on their hourly wage. Secondary data from four rounds of the Community Tracking Study (CTS) Physician Survey (1996-2005). Data are nationally representative of nonfederal office- and hospital-based physicians spending at least 20 hours per week on patient care. A two-part model with site-level fixed effects, time trend variables, and site-year interactions is used to model the relationship between physicians' hourly wage and both their decision to provide any charity care and the amount of charity care provided. Salaried and nonsalaried physicians are modeled separately. Data from each round of the CTS were merged into a single cross-sectional file with 38,087 physician-year observations. The association between physician's hourly wage and the likelihood of providing charity care is positive for salaried physicians and negative for nonsalaried physicians. Among physicians providing any charity care, hourly wage is positively associated with the amount of charity care provided regardless of salaried status. Practice characteristics are also significant. The financial considerations of salaried physicians differ significantly from those of nonsalaried physicians in the decision to provide charity care, but factor similarly into the amount of charity care provided.

Physician Career Satisfaction: Examining Perspectives of the Working Environment

The author examined the relationship among factors influencing the career satisfaction of 2,105 physicians. Data from the 2005 Community Tracking Study Physician Survey were used to obtain 5 latent factors. Structural equation modeling was then applied to extract information on factor interrelationships with physician satisfaction. The main results indicate that underinsurance is negatively associated with physician career satisfaction. Thus, spillover effects that are related to decreased physician satisfaction may increase with greater proportions of underinsurance.

Determinants of primary care physicians' referral pattern: a structural equation model approach.

This study examines patient referrals by primary care physicians (PCP) with nurse practitioners and physician assistants (NP-PA) in their medical practices as compared to practices without them. The study uses data from the Robert Wood Johnson Foundation community tracking study (CTS) Physician Survey, Round I (1996-97) and II (1998-99). Structural equations with binary dependent variables were used to examine the links among managed care, the use of NP-PA, the complexity of patient's conditions, and the number of referrals. PCP's with NP-PA were found to have a greater likelihood of treating patients with complex conditions instead of referring them to specialists. Managed care related variables (i.e., large group practice/HMO, the percentage of patients for whom PCPs acted as gatekeepers, and the percentage of managed care revenue from capitated/prepaid contracts) affected PCP' patient referrals, but only through the increased use of NP-PA. PCP's with NP-PA were also found to provide appropriate care to the complex patients. These findings indicate that NP-PA enable PCP to concentrate on patients with more complex conditions thus reducing the number of referrals. In addition, NP-PA is found to affect the gatekeeper role of PCPs.

Creating a parsimonious typology of physician financial incentives

In order to create an empirically derived parsimonious typology of physician financial incentives that will be useful for future research, we used data from the nationally representative 2004-2005 Community Tracking Study Physician Survey (N = 6,628). Linear regression analyses informed by economic theory were used to identify the combinations of incentives associated with an overall financial incentive to expand services to individual patients. The approach was validated using two nonparametric methods (CART analysis and data mining techniques) and by examining the relationship between the resulting typology and other measures of physician behavior including hours worked, visit volume, and specialty-adjusted income. Of the 6,628 physicians surveyed, approximately 25% (1,605) reported an overall incentive to increase services and 75% (5,023) reported either neutral incentives or incentives to decrease services. Men, who were approximately 75% of respondents, were slightly more likely to report incentives to increase services (P < 0.05). There were no differences in reported incentives according to specialty. We created two typologies (one with eleven categories and the other with a collapsed set of six categories) based on combinations of variables measuring ownership, base compensation methods, and financial incentives. The percentage with an overall incentive to increase services ranges from 6% for employed physicians compensated via fixed salary to 36.7% for owners in low capitation environments with either individual or practice level productivity incentives. The criterion validity of the typology was established by examining the relationship with adjusted physician income, hours worked, and visit volume, which showed generally consistent relationships in the expected direction. A parsimonious typology consisting of six mutually exclusive groups reasonably captures the continuum of incentives to increase service delivery experienced by physicians.

Physician career satisfaction within specialties

BackgroundSpecialty-specific data on career satisfaction may be useful for understanding physician workforce trends and for counseling medical students about career options.MethodsWe analyzed cross-sectional data from 6,590 physicians (response rate, 53%) in Round 4 (2004-2005) of the Community Tracking Study Physician Survey. The dependent variable ranged from +1 to -1 and measured satisfaction and dissatisfaction with career. Forty-two specialties were analyzed with survey-adjusted linear regressionsResultsAfter adjusting for physician, practice, and community characteristics, the following specialties had significantly higher satisfaction levels than family medicine: pediatric emergency medicine (regression coefficient = 0.349); geriatric medicine (0.323); other pediatric subspecialties (0.270); neonatal/prenatal medicine (0.266); internal medicine and pediatrics (combined practice) (0.250); pediatrics (0.250); dermatology (0.249);and child and adolescent psychiatry (0.203). The following specialties had significantly lower satisfaction levels than family medicine: neurological surgery (-0.707); pulmonary critical care medicine (-0.273); nephrology (-0.206); and obstetrics and gynecology (-0.188). We also found satisfaction was significantly and positively related to income and employment in a medical school but negatively associated with more than 50 work-hours per-week, being a full-owner of the practice, greater reliance on managed care revenue, and uncontrollable lifestyle. We observed no statistically significant gender differences and no differences between African-Americans and whites.ConclusionCareer satisfaction varied across specialties. A number of stakeholders will likely be interested in these findings including physicians in specialties that rank high and low and students contemplating specialty. Our findings regarding "less satisfied" specialties should elicit concern from residency directors and policy makers since they appear to be in critical areas of medicine.

Primary care physicians' links to other physicians through Medicare patients: the scope of care coordination.

Primary care physicians are expected to coordinate care for their patients. To assess the number of physician peers providing care to the Medicare patients of a primary care physician. Cross-sectional analysis of claims data. Fee-for-service Medicare in 2005. 2284 primary care physicians who responded to the 2004 to 2005 Community Tracking Study Physician Survey. Primary patients for each physician were defined as beneficiaries for whom the physician billed for more evaluation and management visits than any other physician in 2005. The number of physician peers for each physician was the sum of other unique physicians that the index physician's primary patients visited plus other unique physicians who served as the primary physician for each of the index physician's nonprimary patients during 2005. The typical primary care physician has 229 (interquartile range, 125 to 340) other physicians working in 117 (interquartile range, 66 to 175) practices with which care must be coordinated, equivalent to an additional 99 physicians and 53 practices for every 100 Medicare beneficiaries managed by the primary care physician. When only the 31% of a primary care physician's primary patients who had 4 or more chronic conditions was considered, the median number of peers involved was still substantial (86 physicians in 36 practices). The number of peers varied with geographic region, practice type, and reliance on Medicaid revenues. Estimates are based only on fee-for-service Medicare patients and physician peers, and the number of peers is therefore probably an underestimate. The modest response rate of the Community Tracking Study Physician Survey may bias results in unpredictable directions. In caring for his or her own primary and nonprimary patients during a single year, each primary care physician potentially must coordinate with a large number of individual physician colleagues who also provide care to these patients. National Institute on Aging, American Medical Group Association, and the Robert Wood Johnson Foundation.

Which physicians have access to electronic prescribing and which ones end up using it?

This study examines the availability of electronic prescription and the utilization of e-prescribing by physicians in the US. Nationally representative data from the 2004-2005 Community Tracking Study Physician Survey were used to identify which subgroups of physicians have access to e-prescribing technology and which subgroups are using this technology more or less intensively. Exhaustive Chi-squared Automatic Interaction Detection (CHAID) was employed for statistical data segmentation. Results indicate that the rapidly increasing adoption of electronic prescription is diminished by relatively low physician utilization. E-prescription utilization was segmented among practice size and type. There were also differences in e-prescription use by age, gender, and ethnicity/race in some subgroups. Actual use of e-prescription was very low for female physicians in surgical specialties, psychiatry, and obstetrics/gynecology, and for Hispanic physicians in pediatrics, internal medicine, and family/general practice in solo/two physician practices, medical schools, and hospitals. Insights from segmentation analyses could be used to identify adoption barriers and to develop targeted interventions to accelerate the implementation of e-prescription systems in physician practices.

Effect of Guidelines on Primary Care Physician Use of PSA Screening: Results from the Community Tracking Study Physician Survey

Little is known about the effect of guidelines that recommend shared decision making on physician practice patterns. The objective of this study was to determine the association between physicians' perceived effect of guidelines on clinical practice and self-reported prostate-specific antigen (PSA) screening patterns. This was a cross-sectional study using a nationally representative sample of 3914 primary care physicians participating in the 1998-1999 Community Tracking Study Physician Survey. Responses to a case vignette that asked physicians what proportion of asymptomatic 60-year-old white men they would screen with a PSA were divided into 3 distinct groups: consistent PSA screeners (screen all), variable screeners (screen 1%- 99%), and consistent nonscreeners (screen none). Logistic regression was used to determine the association between PSA screening patterns and physician-reported effect of guidelines (no effect v. any magnitude effect). Only 27% of physicians were variable PSA screeners; the rest were consistent screeners (60%) and consistent nonscreeners (13%). Only 8% of physicians perceived guidelines to have no effect on their practice. After adjustment for demographic and practice characteristics, variable screeners were more likely to report any magnitude effect of guidelines on their practice when compared with physicians in the other 2 groups (adjusted odds ratio= 1.73; 95% confidence interval=1:25-2:38;P=0:001). Physicians who perceive an effect of guidelines on their practice are almost twice as likely to exhibit screening PSA practice variability, whereas physicians who do not perceive an effect of guidelines on their practice are more likely to be consistent PSA screeners or consistent PSA nonscreeners.

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients.

The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.