How Satisfied Are Physicians and Patients When Medical Groups Control Access to Care?
From 1994 to 1996, researchers at the University of California, Los Angeles, School of Medicine examined how the structure and intensity of utilization management in physician groups with capitated contracts affect primary care physician and patient satisfaction.
This was one of the first research projects to look at how the shift in the locus of control from health plans to medical groups is affecting the satisfaction of physicians and patients.
- Patients who had the most difficulty getting access to a specialist were least satisfied with their health plan and most likely to want to change insurance.
- Primary care physicians were less satisfied with the quality of care for capitated patients than for those covered by other insurance types.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $197,013.
As managed care continues to grow as a dominant form of health care delivery, primary care physicians, often working in groups or in affiliations such as independent practice associations (IPAs), are constantly confronting the challenge of providing high quality care while containing costs and utilization. Both medical groups and insurers have developed a variety of utilization management (UM) methods such as prior authorization, retrospective review, second opinions, or retrospective profiling of physician practice patterns. Moreover, the diversity of UM techniques used may be applied with varying degrees of intensity in different groups and for different patients within the same practice group. Before this grant, little work had been done to develop a framework for evaluating the affects of utilization management on physician and patient satisfaction.
As a Robert Wood Johnson Clinical Scholar at UCLA, Kerr developed a taxonomy for describing UM methods and their intensity, and studied the influence of organizational features on the structure and intensity of utilization management. She surveyed 135 physician groups in California to determine how the structure and process of utilization management relates to various group, environmental, physician, and patient characteristics. This grant builds on her previously developed, unique research infrastructure.
The primary goal of this project was to study how the structure and intensity of utilization management in primary care physician groups affects physician and patient satisfaction. Using the results of her previous investigation of internally imposed UM techniques in 94 Southern California physician groups, this project was designed to collect and analyze new data on the satisfaction of physicians and patients in these 94 groups.
To measure physician satisfaction, a survey was distributed to 13 randomly sampled physicians from 89 of the 94 physician groups previously studied. The survey measured the satisfaction of physicians with their practice in general and with utilization management in particular. Researchers explored relationships between various aspects of physician satisfaction and characteristics of physicians and their practices (including the intensity of UM practices.)
Data on patient satisfaction came from the 1993 Health Net patient satisfaction survey (a survey of 17,196 patients enrolled in California's largest network model HMO), which had been augmented by the grantee to include questions regarding access to specialty care and satisfaction with the referral process. Patient satisfaction was measured along four dimensions: convenience of care, doctor quality and technical care, access to specialty care, and access to hospital and emergency room care. Researchers used this information to explore how various aspects of utilization management influenced patient satisfaction.
- Patients who were least satisfied with access to specialty care and with convenience of care were most likely to want to leave their insurance plan. Patients who were denied a referral to a specialist were significantly less satisfied with their physician group, were more likely to want to leave the plan, and less likely to recommend the group to a friend. Indeed, patients who belong to physician groups with high-intensity pre-authorization were less satisfied than patients in low-intensity pre-authorization groups. Because limiting direct access to specialists is a cardinal feature of most managed care organizations, the potential impact of these limitations on disenrollment warrants on-going attention by researchers.
- Primary care physicians are significantly less satisfied with the quality of care they are able to deliver to patients covered by capitated contracts than those covered by other payment sources. However, those in medical group practices (vs. IPAs) with a higher percentage of capitated patients were more satisfied with capitated care.
- Pre-authorization procedures have a significant impact on physician satisfaction. Physicians who reported that their groups required pre-authorization for greater numbers of specialty referrals and tests were less satisfied. The longer it takes for pre-authorization requests to be decided, the less satisfied physicians are with many aspects of their practice. Also, physicians who have fewer pre-authorization requests denied are more satisfied than those who have more requests denied.
- Physicians who reported receiving more educational tools for managed care practice and written practice guidelines were more satisfied than those who felt they received fewer such tools.
- In general, physicians who are reimbursed for capitated patients by salary are more satisfied than those receiving fee-for-service and capitated reimbursement.
The grantee has submitted three articles based on this project to journals for review: one was published in The Journal of the American Medical Association and another is in press in Medical Care Research Review. One other paper based on this study is currently being written. Two poster sessions, one on patient satisfaction and one on physician satisfaction, were presented at the National Meeting of the Society of General Internal Medicine in Washington, DC, in May 1996 and May 1997 respectively. Abstracts from the two presentations were published in the Journal of General Internal Medicine in 1996 and 1997. The grantee mailed a summary, "Report of Results from the Primary Care Physician Survey," to medical directors of the physician groups that participated in the 1995 survey. See the Bibliography for details.
AFTER THE GRANT
In 1997, the grantee and another former RWJ Clinical Scholar, Steve Katz, M.D., M.P.H., will submit a follow-up proposal to the Foundation under its initiative, Strengthening the Patient-Provider Relationship in a Changing Health Care Environment. In the coming year, the grantee will also submit a proposal to the Veterans' Health Administration for a prospective study of the effects of utilization management on patient outcomes, physician satisfaction, and overall quality of care.
GRANT DETAILS & CONTACT INFORMATION
Utilization Management Effects on Physician/Patient Satisfaction
University of California, Los Angeles, School of Medicine (Los Angeles, CA)
Dates: October 1994 to June 1996
Eve A. Kerr, M.D., M.P.H.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Kerr EA, Hays RD, Lee ML, and Siu AL. "Does Dissatisfaction with Access to Specialists Affect Desire to Leave a Managed Care Plan?" Medical Care Research and Review, 55(1): 5977, 1998.
Kerr EA, Mittman BS, Hays RD, Siu AL, Leake B, and Brook RH. "Primary Care Physicians' Satisfaction With Quality Care in California Capitated Medical Groups." Journal of the American Medical Association, 278(4): 308312, 1997. Abstract available online.
Kerr, Eve A., Ron D. Hays, and Albert L. Siu. "Primary Care Physicians' Satisfaction with the Quality of Care in Capitated Medical Groups." Accepted by the Journal of General Internal Medicine, 12(Supp. 1): 83, 1997. To be presented as a poster at the National Meeting of the Society of General Internal Medicine, Washington, D.C.; May 1997.
Kerr, Eve A., Ron D. Hays, and Albert L. Siu. "Does Dissatisfaction with Access to Specialists Affect the Desire to Leave a Health Plan?" Journal of General Internal Medicine, 11(1): 77, 1996. Presented as a poster at the National Meeting of the Society of General Internal Medicine, Washington, D.C.; May 1996.
Report prepared by: James Wood
Reviewed by: Marie Lyons
Program Officer: Lewis G. Sandy