Health Maintenance Organization Physicians Research Articles

Medicare Beneficiaries More Likely To Receive Appropriate Ambulatory Services In HMOs Than In Traditional Medicare

With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and older Medicare HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. Our results suggest that the positive effects of more-integrated delivery systems on the quality of ambulatory care in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments.

Modifying prescribing behaviour of angiotensin receptor blockers by selectively rescinding managerial prior authorization requirements for losartan

To evaluate whether rescinding the prior authorization (PA) requirement (managerial pre-approval) for losartan in an health maintenance organization (HMO) could reduce prescribing of the more expensive angiotensin receptor blockers (ARBs). HMO physicians were notified that losartan would no longer require PA, and appropriate changes were made to the electronic prescribing computer program. The monthly distribution by drug of the number of prescriptions for ARBs dispensed for new patients was calculated before and after the policy change from data captured from electronic records. The proportion of patients (percentage and 95% confidence interval) treated with losartan who met the criteria for treatment with ARBs (hypertension or cardiac insufficiency in patients who have developed adverse effects in response to angiotensin-converting enzyme inhibitors or macroproteinuria) during the first month after the PA requirement was rescinded was calculated. The total number of PA requests for ARBs declined by 48.6% from 961 in December 2008, the month before the policy change, to 494 the following January, rising again to 651 during January 2010. Prescription incidence changed from 121 to 255 patients treated per month (114% increase) for losartan, from 15 to 16 (6.7% increase) for candesartan, and from 89 to 71 (20.2% decrease) for valsartan. The duration of effect for decrease in ARB requests for the more expensive drugs was approximately 1 year. Only 23.3% (95% confidence interval 18.1-28.4) of patients receiving losartan met the criteria for receiving ARBs. Rescinding the PA requirement for this drug alone was an effective limited-duration strategy for reduction of prescription of relatively expensive drugs.

The influence of managed care on generic prescribing rates: an analysis of HMO physicians

Retail expenditures on prescription drugs continue to grow annually by double digits, while the share of prescriptions dispensed as generics remains relatively constant. Efforts to curtail rising drug expenditures have been exhibited by Managed Care Organizations (MCOs), yet drug expenditures continue to rise. Using the National Ambulatory Medical Care Survey (NAMCS) for 1997–2000, this study examines how managed care, specifically Health Maintenance Organizations (HMOs), influence the physician's decision to prescribe the generic version of a multi-source drug. The findings show that HMO physicians are not significantly more likely to prescribe generic drugs than non-HMO physicians. Among HMO physicians, different cost reduction tools effect generic prescribing behaviour in different ways, with, the size of the effect depending on the patient and physician relationship with the HMO.

Are HMO physicians more price sensitive in prescribing brand‐name drugs?

Purpose – The purpose of this paper is to estimate whether health maintenance organizations (HMO) physicians are more price sensitive than non‐HMO physicians in their prescribing behavior of brand‐name substitutes.Design/methodology/approach – The study uses physician level data and a set of 13 drugs for the years 1997‐2000 to estimate the price sensitivity of HMO and non‐HMO physicians. A two‐part model is used to measure the price elasticity of brand‐name prescribing for HMO physicians. The first part uses a logit model to examine the physician's choice to prescribe the same drug to all patients with the same medical condition, or whether physicians alternate prescriptions among brand‐name substitutes. The second part employs OLS to estimate the influence of managed care, i.e. HMOs, on physician price sensitivity.Findings – The results suggest that HMO physicians are less likely than non‐HMO physicians to prescribe a common drug to all patients with a specific medical condition, but rather HMO physician...

Differences in Prescription Drug Use in HMO and Self-insured Health Plans

Using pharmacy benefits manager claims data, this study analyzed how cost-management techniques including cost sharing affected enrollees in health maintenance organizations (HMOs) versus employer-sponsored fee-for-service plans. Because HMOs bear the risk of pharmaceutical costs and influence the prescribing practices of the physicians in their network, we expected different patterns of prescription use, such as proportionately more generic medications in HMOs. Also, because HMO physicians are likely to prescribe relatively more drugs for high-severity conditions, HMO enrollee demand should be less price sensitive. The impact of cost sharing was found to be significantly less for HMOs. A 5-dollar increase in copayments decreased expenditures by 16 percent in fee-for-service plans but only by 1 percent in HMOs. Furthermore, when cost sharing was set at zero, HMO plans were found to have significantly fewer and cheaper medications, resulting in lower per-enrollee medication expenditures.

STUDENTJAMA. Career satisfaction among physicians.

DESPITE REPORTS OF DISSATISFACTION AMONG PRACTICING PHYsicians and a 22% decrease in applications to US medical schools since 1997, recent data suggest that the majority of physicians remain satisfied with their careers, although there may be substantial variability across geographical areas. In a nationally representative telephone survey of physicians from 1997 to 2001, we found that more than 80% of physicians with direct patient care responsibilities were somewhat or very satisfied with their careers. Physician career satisfaction appears to be a complex function of a number of variables. Overall career satisfaction among physicians may remain high despite decreases in some of these domains. The Society of General Internal Medicine (SGIM) Career Satisfaction Study Group defined 10 domains of professional satisfaction. Among the highest predictors of global job satisfaction were patient care issues and relationships with patients and colleagues. The SGIM study group defined autonomy as “independence of action,” including the ability to treat patients according to the best clinical judgment. We found that both primary care physicians and specialists who rated their autonomy lower and those that reported more difficulty obtaining high-quality outpatient services and inpatient services were more likely to report decreased satisfaction with their careers over the 4-year period. Similarly, in a crosssectional study, Stoddard et al found clinical autonomy to be significantly related to career satisfaction. Conversely, while physicians may be largely satisfied with their careers in medicine, they may be less satisfied with particular aspects of practice, including income, control over personal time, and the administrative aspects of practice. In a 1999 study in Massachusetts, more than 60% of physicians reported dissatisfaction with managed care. Many of these physicians also rated the fee schedules or capitation rates they received from managed care companies as “fair” or “poor.” Similarly, the study by Stoddard et al found that the level of income was associated with satisfaction. Another study from the SGIM study group found that physicians’ dissatisfaction with pay was associated with an increased likelihood of leaving their jobs within 2 years. Rates of increases in physician income have barely kept pace with inflation. In addition, within medicine, primary care specialties have been particularly affected because of continued increases in practice expenses accompanied by relatively flat reimbursement rates. In our national longitudinal study, we found that primary care physicians who reported lower income were significantly more likely to become less satisfied, although primary care physicians with increases in income did not become more satisfied over time. Among specialists, neither increases nor decreases in income were related to changes in satisfaction. Another aspect of practice that has changed in the recent past is control over work. Whereas physicians once practiced primarily alone or in small autonomous groups, they now are more likely to be employed in large groups and are increasingly subjected to profiling, administrative requirements, and preapproval for procedures and treatments. Financial constraints are also prevalent. Patients report less trust in physicians, and physicians are no longer respected as highly as they once were. Among the most important changes related to this area of practice are control over work and personal time. Linzer et al reported that physicians in health maintenance organizations were less satisfied with their careers and that the adequacy of time with patients was an important predictor. The data on physician satisfaction cannot be fully understood without examining the principal domains determining physician career satisfaction. Although physicians have traditionally derived career satisfaction from their services to patients, other aspects of satisfaction including income and personal time are also important and appear to be more subject to change over time. If the balance between these factors continues to shift, this could potentially lead to increasing levels of dissatisfaction among physicians.

HMOs and physician conflicts of interest.

In a recent issue of this journal, Francis Beckwith's "The Ethics of Referral Kickbacks and Self-Referral and the HMO Physician as Gatekeeper: An Ethical Analysis" provided an admirably provocative defense of the claim that Health Maintenance Organization (HMO) physician gatekeepers are morally indistinguishable from physician referral kickbacks and self-referrals. Here I will argue that Beckwith's defense is weak. I will also make some tentative suggestions about approaching the issue of physician conflicts of interest.

Satisfaction, commitment, and psychological well-being among HMO physicians.

To identify the factors that predict professional satisfaction, organizational commitment, and burnout among physicians working for health maintenance organizations (HMOs). Data came from mail surveys of Kaiser Permanente physicians in the Northwest and Ohio regions. The average response rate was 80% (n = 608). The single most important predictor for all 3 outcomes was a sense of control over the practice environment. Other significant predictors included perceived work demands, social support from colleagues, and satisfaction with resources. The relative importance of these predictors varied, depending on the outcome under consideration. All 3 outcomes were also related to physician age and specialty. Older physicians had higher levels of satisfaction and commitment and lower levels of burnout. Pediatricians were more satisfied and committed to the HMO and were less likely to burn out. Physicians who perceive greater control over the practice environment, who perceive that their work demands are reasonable, and who have more support from colleagues have higher levels of satisfaction, commitment to the HMO, and psychological well-being. Interventions and administrative changes that give physicians more control over how they do their professional work and that enhance social supports are likely to improve both physician morale and performance.

HMO penetration and physicians' earnings.

The goal of this study is to estimate whether cross-sectional variations in enrollment in health maintenance organizations (HMOs) affected physicians' earnings and hourly income in 1990. Using data from a nationally representative sample of 4,577 younger physicians (<45 years) conducted in 1991, we estimated a partial reduced-form model of physicians annual income and per hour income. We tested whether HMO penetration is endogenous and used the instrumental variables approach to obtain unbiased estimates. HMO penetration had a negative and statistically significant impact on physicians earnings in 1990. A doubling of the average level of HMO penetration in the market is estimated to reduce annual earnings by 7% to 10.7%, and hourly earnings by approximately 6% to 9%. It appears that HMOs were successful in reducing physicians' annual and per hour earnings in 1990, presumably through a combination of fewer visits and lower payment rates for people covered by HMOs. Although these results cannot be generalized to all physicians, the experience of a younger cohort of physicians may still be a good indicator of the future effects of HMOs because younger physicians may be more susceptible to market forces than older and more established physicians. Moreover, these results may be somewhat conservative because they reflect market behavior in 1990, several years before the rapid growth and more aggressive market behavior of HMOs in recent years.

HMO physicians' use of referrals

Clinical uncertainty is a source of variation in medical decision-making as well as a source of work-related stress. Increasing enrollment in organized health care systems has intensified interest in understanding referral utilization as well as issues such as physician dissatisfaction and burnout. We examined whether primary care physicians' affective reactions to uncertainty and their job characteristics were associated with use of referrals and burnout. Data came from mail surveys of primary care physicians practicing in two large group model health maintenance organizations (HMOs) in the USA. Consistent with past research, we found that younger physicians had higher referral rates than older physicians, and that general internists had higher rates than either family practitioners or pediatricians. Greater stress from uncertainty increased referrals and referrals were negatively correlated with heavier work demands (patient visits per hour). Greater stress from uncertainty, perceived workload (too high) and a sense of loss of control over the practice environment were associated with higher levels of burnout.

Managed care in the Northern California Kaiser Permanente health care system

Kaiser Permanente in Northern California is a group model health maintenance organization (HMO) that contracts with The Permanente Medical Group, Inc. (TPMG) to provide care for health plan members. TPMG is the largest (for-profit) private group practice in the world, with 3600 physicians in Northern California, including 62 urologists, providing care to 2.5 million health plan members. Recent changes in health care financing and delivery mandate an HMO–physician relationship which addresses issues of cost, quality of care, and the needs of physicians.

Dimensions and correlates of physician work satisfaction in a midwestern city.

The purpose of this study was to examine the dimensions of physician work satisfaction across a variety of medical specialties and practice settings. A modified version of the Scheckler et al survey instrument was mailed to all physicians in Marion County, Indiana. Forty-two percent (777) of the eligible physicians responded. Exploratory factor analysis and internal consistency measures were used to assess the instrument's validity and reliability. Multivariable linear regression was used to predict global and summary scale scores. Four dimensions of physician work satisfaction were identified: relationships with patients (k = 6, alpha = 0.81), autonomy in clinical decision-making (k = 8, alpha = 0.81), office resources (k = 7, alpha = 0.87), and professional relationships (k = 5, alpha = 0.82). Most (73%) of the physicians were satisfied with their overall practice, and the majority were also satisfied with their income. Significant differences were observed in the sources and magnitude of physician work satisfaction across medical specialty, practice setting, and financial arrangement. Physicians in private practice were most satisfied with their overall practice and office resources, whereas physicians in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decision-making. Physicians not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practice. Among primary care physicians, family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their medical practices. The modified version of the Scheckler et al instrument is a reliable and valid measure of physician work satisfaction. Increases in the market share of managed care have differentially affected the work satisfaction of physicians based on their medical specialty, practice setting, and financial arrangements.

Physicians Who Report Health Insurance Fraud and Their Practice Type: Health Maintenance Organization vs Fee-for-Service

Farber et al 1 found that physicians practicing in health maintenance organization (HMO) settings compared with those in fee-for-service settings were more likely to suggest reporting patients committing health insurance fraud in the scenarios presented in their questionnaire. In their discussion, the authors opine, Physicians who practice in staff-model HMOs... may feel more allegiance to third-party payers than physicians working primarily in a fee-for-service practice. In addition, physicians in an HMO setting may have a greater financial incentative to report insurance fraud, because their financial well-being is more directly related to the financial health of the third-party payers. An alternative hypothesis explaining the difference is that fee-for-service physicians, in reporting patients committing insurance fraud, may directly affect the likelihood that their fees will be paid. That is, fee-forservice physicians may find that their decision is more directly related the financial health of their own practice, whereas HMO physicians are watching

A reasoned action approach to physicians' utilization of drug information sources.

The effects of attitude and subjective norm were investigated on physicians' intention to use seven drug information sources: the PDR, medical textbooks, medical journals/newsletters, pharmaceutical manufacturers' literature, pharmaceutical manufacturers' representatives, other physicians, and pharmacists. The effects of past behavior and practice characteristics were also examined. An eight-page mail questionnaire queried health maintenance organization physicians on their intention to use, attitude (emotional response) and subjective norm (colleagues' approval/disapproval) toward use of each source when searching for drug information on a fictitious, new H2 antagonist agent. Responses were received from 54% (108) of the 200 physicians surveyed. Positive attitudes toward use had the greatest influence upon intention to use each of the sources (b > or = .40) (except for pharmacists, for which subjective norm was the most important predictor (b = .31)). Past behavior directly affected intention to use the PDR (b = .27), and pharmaceutical manufacturers' literature (b = .26). The effects of attitude and/or subjective norm on intention to use non-commercial sources of drug information were moderated by the practice characteristics. These findings suggest that physicians' use of drug information sources is strongly influenced by their attitudes toward use. In addition, the importance of situational contingencies should not be overlooked when investigating the use of drug information sources.

The Effect of an Education and Feedback Intervention on Group-Model and Network-Model Health Maintenance Organization Physician Prescribing Behavior

The authors evaluated the effect of an educational and feedback intervention on H2-blocker prescribing patterns and determined, if such effects differed for network- versus group-model health maintenance organization (HMO) physicians and in academic versus nonacademic settings. Physicians were randomized to receive an educational memorandum alone or combined with feedback regarding their individual prescribing behavior. The memo suggested preferred use of an H2-blocker (cimetidine) that would be less expensive to the HMO. Prescribing was monitored during the 6 months before and after the intervention. The study was undertaken at the primary care practices of a mixed group- and network-model university-affiliated HMO. Thirty group-model (at two academic and four nonacademic sites) and 33 network-model (all in full-time private practice) primary care physicians participated in the study. The analysis utilized weighted and unweighted analysis of covariance of the change in physicians' cimetidine-prescribing rates between the baseline and study periods. A significant response to the intervention was noted among academic and nonacademic group-model HMO physicians, but not among network physicians (adjusted mean absolute prescribing changes of +9.9% and +8.9% versus -2.8%, P = .02). There was no difference in prescribing change based on type of intervention (education versus feedback). The authors conclude that a simple passive educational intervention can be effective at changing group-model HMO physician behavior.

The Effect of an Education and Feedback Intervention on Group-Model and Network-Model Health Maintenance Organization Physician Prescribing Behavior

The Effect of an Education and Feedback Intervention on Group-Model and Network-Model Health Maintenance Organization Physician Prescribing Behavior

I. Essay: Managed Care: Promise and Concerns

I. Essay: Managed Care: Promise and Concerns

The effect of a comprehensive breast screening program on self-reported mammography use by primary care physicians and women in a health maintenance organization.

Mammography use is increasing in the United States, but most women older than 50 years still are not being screened regularly. A multicomponent program, with components for women and physicians, was conducted to increase screening among women aged 50 to 74 years in an independent practice association (IPA)-model health maintenance organization (HMO). The participating women and physicians were surveyed in four waves to evaluate the program. We report on changes in mammography practices by both women and physicians between 1988 (preintervention year) and 1992 (postintervention year). Bivariate and multivariate analyses were calculated. The proportion of responding HMO physicians who recommended annual mammograms for women aged 50 to 74 years increased by 16 percent from 1988 to 1992 compared with an increase of 10 percent for control group physicians (nonsignificant). There was a 30 percent increase from 1988 to 1992 in the proportion of HMO women respondents who reported having had a mammogram in the past year compared with a 19 percent increase among control group women. The difference between these differences was highly significant. The intervention had the strongest effect on women with incomes of less than $30,000. A multicomponent program in an IPA-model HMO resulted in significant increases in the proportion of HMO women who had mammograms. Similar approaches should be tested in other settings.

Counselling patients to make lifestyle changes: the role of physician self-efficacy, training and beliefs about causes.

Three factors that might help explain the extent to which physicians counsel patients to quit smoking and lose weight were examined: counselling self-efficacy, training in behaviour change and beliefs about causes of smoking and being overweight. More aggressive counselling was defined as counselling more patients per month and following up on counselling recommendations. Questionnaires were returned by 85 health maintenance organization physicians. As predicted, physicians with a stronger sense of counselling self-efficacy, and those who had received education in health behaviour change techniques were more aggressive counsellors. Motivational strategies were also explored. Physicians' beliefs about the causes of smoking and being overweight were related to the use of some types of strategies. Implications for increasing physician counselling patients to make behaviour changes are discussed.

Critical factors in recruiting health maintenance organization physicians

Critical factors in recruiting health maintenance organization physicians