The Health Care Manager Volume 33, Number 1, pp. 38–44 Copyright # 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Antecedents of Care by Physicians Satish P. Deshpande, PhD; Samir S. Deshpande The objective of this study was to examine factors impacting physicians’ quality of care. This study used the Center for Studying Health System Change’s 2008 Health Tracking Physician Survey data set consisting of 4720 physicians belonging to the American Medical Association. Regression analysis indicated that time with patient, career satisfaction, use of information technology for patient information, and income had a significant, positive impact on perception of high-quality care by physicians. Threat of malpractice lawsuits, percent revenue from Medicaid, and type of practice had a significant negative impact on perception of high-quality care by physicians. Among all the variables examined in our study, time with patient had the greatest impact on perception of high-quality care by physicians. Key words: health care, physicians, quality care
A
LTHOUGH THE US economy spends billions of dollars to support the health care system, questions are still raised on the consistency of quality of care for patients.1-5 Betterquality care can save the US economy nearly $400 billion a year in health care costs.6 One of the aims of the Patient Protection and Affordable Care Act (PPACA) signed into law by President Barack Obama on March 23, 2010, was to reduce health care costs while maintaining the standard of care. Among other things, it capped out-of-pocket expenses, fully covered preventive care, created insurance exchanges to make private insurance affordable, and banned insurance companies from denying insurance coverage due to preexisting medical conditions. In addition, it enabled organizations such as the Centers for Medicare & Medicaid Services to set up individual measures to assess quality of new programs. The expansion of PPACA in 2014 is expected to make the existing shortage of doctors,
Author Affiliations: Department of Management, Western Michigan University (Dr S.P. Deshpande), and Department of Chemistry, Kalamazoo College (Mr S.S. Deshpande), Kalamazoo, Michigan.
especially primary care physicians, worse. In addition, nearly one-third of the current physicians are expected to retire within the next 2 decades. The American Medical Association expects the shortage of doctors across all specialties to reach 130 000 by 2025.7 This is despite any additional doctors expected to enter the profession because of expanded enrollments in current medical schools and a gradual increase in the number of new medical schools in the United States. In addition, less than 20% of medical school graduates are expected to end up working in primary care.8 Clearly, this legislation will put additional stress on a health care system where long office waits have become the norm. The purpose of this research was to examine factors that impact the ability of a physician to provide quality care to his or her patients. A better health system can be achieved only if patients have access to reliable, high-quality care. Unreliable or inadequate treatment often leads to unnecessary hospitalization or even death. For example, research has found that nearly $17 to $19 billion in additional Medicare spending takes place because of unplanned and unnecessary hospitals readmissions.9,10 In addition, better quality and safety could save nearly 90 000 lives a year.6
The authors report no conflicts of interest. Correspondence: Satish P. Deshpande, PhD, Department of Management, Western Michigan University, Kalamazoo, MI 49008-5429 ([email protected]). DOI: 10.1097/01.HCM.0000440622.39514.44
METHODS Data The data for this research investigation came from the first round of the Health Tracking
38
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Antecedents of Care by Physicians Physician Survey (HTPS) conducted between February and October 2008.11 The Center for Studying Health System Change is a Washington, DC–based organization founded in 1995 by the Robert Wood Johnson Foundation. It is well known for conducting detailed independent surveys to recognize trends in the US health care system. The objective of Center for Studying Health System Change is to be a resource for health care policy decision makers. It does not take a position on any specific health care policy. Documentation on the survey and public-use data was obtained through the InterUniversity Consortium for Political and Social Research at http://www.icpsr.umich.edu/icpsrweb/ HMCA/studies/27202. The 2008 HTPS replaced the 1996-1997, 1998-1999, 2000-2001, and 2004-2005 Community Tracking Study Physician Surveys. Whereas the Community Tracking Study focused on 60 nationally representative communities, HTPS is a nationally representative sample of American Medical Association physicians. The HTPS Methodology Report at http://www.hschange.com/ CONTENT/1085/1085.pdf provides detailed information on study design, sampling, stratification process, data management, and data collection procedures used in this survey. This survey collected information on a variety of topics including career satisfaction, physician time allocation, use of health information technology (IT), and physicians’ perception of their ability to deliver care. The HTPS data set consists of 4720 physicians who provided direct patient care for at least 20 hours per week. It does not include federal employees, graduates of foreign medical schools who were only temporarily licensed to practice in the United States, residents, interns, and fellows. Listwise deletion of missing values left a sample of 4061 physicians for the study. Dependent variable The dependent variable was based on the following item on the survey, ‘‘It is possible to provide high-quality care to all my patients.’’ This item was measured on a 5-point scale ranging from ‘‘strongly agree’’ (5) to ‘‘strongly disagree’’ (1).
39
Independent variables Time with patient was measured by asking the physicians about their agreement with the statement that they had adequate time to spend with patients during their office visits. The 5-point scale used to measure time with patient ranged from ‘‘strongly agree’’ (5) to ‘‘strongly disagree’’ (1). Threat of malpractice was measured using the following items: they were concerned that they will be involved in a malpractice case sometime in the next 10 years, they felt pressure in their day-to-day practice by threat of malpractice litigation, they ordered tests or consultations to avoid appearance of malpractice, they asked for a consultation to reduce risk of being sued, and they rely less on clinical judgment rather than technology to make a diagnosis because of threat of malpractice lawsuit. These items were also measured on a 5-point scale (5 = strongly agree, 1 = strongly disagree). Career satisfaction was measured using the following item, ‘‘Thinking very generally about your satisfaction with your overall career in medicine, would you say that you are currently very dissatisfied (1), somewhat dissatisfied (2), neither satisfied nor dissatisfied (3), somewhat satisfied (4), or very satisfied (5)?’’ The 2 independent variables, percent practice revenue from Medicare and percent practice revenue from Medicaid, were coded on a 5-point categorical scale (1 = 0%, 2 = 1%-25%, 3 = 26%-50%, 4 = 51%-75%, and 5 = 76%%-100% ). The physician’s practice type was categorized into 1 of the following 6 classifications: 1 = solo/2 physicians, 2 = group of 3 or more physicians, 3 = health maintenance organization, 4 = medical school, 5 = hospital-based physicians, and 6 = other. The data set classified physicians as either primary care physicians (1) or nonprimary care physicians. Physicians in the specialty areas of internal medicine, family medicine or general medicine, and pediatrics were classified as primary care physicians (1). Use of IT in clinical practice, use of IT for patient information, and use of IT for prescriptions were measured on the following scale: 3 = IT available and used, 2 = IT available and not used, 1 = IT not available. Use of IT in clinical practice was measured using 6 items
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
40
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
that covered use of IT for obtaining recommended guidelines, decision support for diagnostic and treatment recommendations, generating reminders for clinicians about preventive services, generating reminders for other needed patient follow-up, generating reminders to patients about preventive services, and e-mailing patients about clinical issues. Use of IT in prescriptions was measured using 4 items that examined use of IT to obtain information on potential patient drug interactions, obtain information on formularies, write prescriptions, and transmit prescriptions to pharmacy. Use of IT in patient information was measured using 6 items that examined the use of IT to access patient notes, order diagnostic tests, view results of diagnostic tests, exchange clinical data and images with other physicians, exchange clinical data and images with hospitals and laboratories, and access information on patients’ preferred language. Overall use of IT was a constrict that consisted of all 16 IT usage–related variables. The data set also measured various demographic variables such as age (1 = 1940 or earlier, 2 = 1941-1945, 3 = 1946-1950, 4 = 1951-1955, 5 = 1956-1960, 6 = 1961-1965, 7 = 1966-1970, 8 = 1971 or later), sex (1 = male, 0 = female), experience (8 = 2005 or later, 7 = 2001-2004, 6 = 1996-2000, 5 = 1991-1995, 4 = 1986-1990, 3 = 1981-1985, 2 = 1976-1980, 1 = 1975 or earlier), race (1 = Hispanic, 2 = white, 3 = black, 4 = Asian or Pacific Islander, 5 = other/mix), and income (6 = more than $300 000, 5 = $250 001 to $300 000, 4 = $200 001 to $250 000, 3 = $150 001 to $200 000, 2 = $100 001 to $150 000, 1 = less than $100 000). More information and the variables used in this study are available at http://www.icpsr.umich.edu/icpsrweb/HMCA/ studies/27202. Statistical analysis Statistical analysis was done using SPSS PASW Statistics 18.0 (SPSS Inc, Chicago, Illinois). First calculated were the means and SDs of all the variables used in this study; next, we calculated the zero-order correlations among the variables. Cronbach’s of construct variables (threat of malpractice, use of IT in clinical practice, use of IT for patient information, and use of IT for
prescriptions) were then calculated. Last was ordinary-least-square regression analysis to examine the impact of our independent variables on our dependent variable and calculate the overall R 2 value of the model.
RESULTS Descriptive statistics of the variables used in this study are presented in Table 1. An average physician ‘‘somewhat agreed’’ with the statement that it was possible for the physician to provide high-quality care to patients. Forty percent of the respondents were primary care physicians. An average physician was a white non-Hispanic male who was born between 1956 and 1960 and had an annual compensation between $150 000 and $200 000. Reliabilities of the construct variables are presented on the diagonal of Table 2. Cronbach’s for threat of malpractice, use of IT in clinical practice, use of IT for patient information, and use of IT for prescriptions were .89, .77, .76, and .82 respectively. Table 2 also presents zeroorder intercorrelations among the variables. Correlation coefficients in Table 2 indicate that there was a linear relationship between a number of independent variables and our dependent variables. But correlation outcomes must be inferred with caution, particularly when Table 1. Descriptive Statistics of the Variables Variables
Mean
SD
n
High-quality care 3.93 1.16 4061 Time with patient 3.46 1.35 4061 Threat of malpractice 3.62 1.02 4061 Career satisfaction 4.03 1.09 4061 Percent revenue from Medicare 30.78 22.65 4061 Percent revenue from Medicaid 16.42 20.13 4061 Type of practice 2.40 1.51 4061 Primary care physician 0.40 0.49 4061 Use of IT in clinical practice 1.89 0.59 4061 Use of IT for patient information 1.99 0.67 4061 Use of IT for prescriptions 1.96 0.71 4061 Age 4.97 1.95 4061 Male 0.74 0.44 4061 Race/ethnicity 2.31 0.82 4061 Income of physician 3.48 1.68 4061 Abbreviation: IT, information technology.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
41
Abbreviation: IT, information technology. Correlations 0.03, 0.04, 0.03, and 0.04 significant at P .05; correlations greater than 0.05 and less than
0.05 significant at P .01. Reliabilities are on the diagonal in parenthesis.
1.00 1.00 0.06 1.00 0.09 0.30 1.00 0.22 0.09 0.00 (0.76) 0.12 0.04 0.02 0.01 (0.82) 0.63 0.15 0.01 0.03 0.11 (0.77) 0.54 0.59 0.12 0.03 0.05 0.00 1.00 0.08 0.03 0.08 0.08 0.14 0.05 0.41 1.00 0.08 0.08 0.24 0.14 0.14 0.09 0.00 0.02 1.00 0.35 0.06 0.04 0.09 0.05 0.06 0.11 0.07 0.15 1.00 0.21 0.06 0.08 0.02 0.02 0.03 0.05 0.14 0.03 0.12 1. High-quality care 2. Time with patient 3. Threat of malpractice 4. Career satisfaction 5. Percent revenue Medicare 6. Percent revenue Medicaid 7. Type of practice 8. Primary care physicians 9. Use IT in clinical practice 10. Use IT for patient info 11. Use IT for prescriptions 12. Age 13. Male 14. Race/ethnicity 15. Income of physician
1.00 0.55 0.18 0.30 0.01 0.08 0.12 0.09 0.00 0.00 0.03 0.10 0.05 0.00 0.10
1.00 0.24 0.29 0.02 0.04 0.11 0.11 0.03 0.07 0.09 0.15 0.04 0.04 0.01
(0.89) 0.21 0.10 0.07 0.03 0.05 0.01 0.02 0.01 0.10 0.09 0.03 0.12
1.00 0.07 0.01 0.03 0.01 0.06 0.04 0.03 0.03 0.01 0.00 0.11
8 7 6 5 4 3 2 1
Table 2. Correlations Among the Variables (n = 4061)
9
10
11
12
13
14
15
Antecedents of Care by Physicians
ascertaining causative relationships. Significant correlation coefficients do not indicate causation because a superficial correlation may exist because of the impact of a third variable on the 2 variables being investigated. In our sample, we notice that a number of independent variables are significantly intercorrelated. Thus, a better test to examine the impact of independent variables on the dependent variable is regression analysis. Regression analysis results are presented in Table 3. Time with patient, career satisfaction, use of IT for patient information, and income had a significant positive impact on perception of high-quality care by physicians. Threat of malpractice lawsuits, percent revenue from Medicaid, and type of practice had a significant negative impact on perception of high-quality care by physicians. Among all the variables examined in our study, time with patient had the greatest impact on perception of high-quality care by physicians. DISCUSSION Although the American medical system has some of the best medical treatment available Table 3. Ordinary Least Squares Regression Results Variables
t
Time with patient .49 a 34.70 Threat of malpractice .04 a 3.31 Career satisfaction .14 a 10.19 Percent revenue from Medicare .01 0.81 Percent revenue from Medicaid .03 b 2.26 Type of practice .08 a 5.37 Primary care physician .00 0.25 Use of IT in clinical practice .01 0.72 a 3.66 Use of IT for patient information .07 Use of IT for prescriptions .02 0.85 Age .01 1.08 Male .00 0.02 Race/ethnicity .02 1.17 Income .07 a 4.68 F 148.01 a R2 0.34 0.34 Adjusted R2 n 4061 Abbreviation: IT, information technology. a P .01. b P .05.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
42
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
in the world, it often fails to provide consistent high-quality care to all its citizens. More than 95 000 deaths per year occur in the United States due to medical error.12 A number of factors such as growing demand for health care, aging population, and variation in treatment have put quality of health care in the national spotlight. In this study, time with patients was the biggest predictor of quality care by physicians. Besides lower quality of care, inadequate time with patients also has been shown to negatively impact health care outcomes such as patient satisfaction, trust, and malpractice claims.13 Our study suggests that older physicians are significantly more likely to spend more time with their patients than younger physicians (r = 0.15). Merritt Hawkins and Associates in their survey of older physicians report that 68% of physicians between 50 and 65 years of age perceive physicians coming out of training today to be less dedicated and hardworking than them when they came out of training.14 In addition, 3 of 4 older physicians report ‘‘patient interaction as the single greatest source of professional satisfaction.’’14 On the other hand, it is also possible that older physicians are closer to retirement, are more likely to work part-time, reduce the number of patients they see, stop accepting new patients, and are less influenced by payment plans where compensation is tied to the number of patients seen. Future research needs to examine the impact of age and other potential factors that could influence the amount of time spent by physicians with patients. Career satisfaction of physicians had a significant positive impact on perceived quality of care. Thus, understanding the causes of dissatisfaction is important, as it can help increase quality of patient care. Previous research has identified a number of factors that can influence career dissatisfaction, including physician autonomy, financial constraints of managed care, ownership in practice, and the ability to make clinical decisions.15 In addition, satisfied physicians have been shown to provide better attention to their patients and less likely to adopt risky prescription practices.16 The threat of malpractice lawsuits had a significant, negative impact on quality of care by
physicians. The threat of malpractice lawsuits has given rise to defensive medical practices by physicians, where physicians order unnecessary or excessive tests and procedures to protect themselves from lawsuits.17 Threat of malpractice lawsuits impacts quality of care in various ways: first, it results in physicians adopting highly aggressive treatments in low-risk conditions; second, it increases the cost of delivery of care because of defensive medication—it is estimated that nearly $60 billion are spent on defensive medication in the United States every year; third, it creates a shortage of physician in highly litigious states encouraging migration of physicians to less litigious states; fourth, it also has an impact on the supply of physicians in specialties such as obstetrics and gynecology, which are more likely to be sued. Finally, it makes physicians less ‘‘candid’’ and more ‘‘hardnosed’’ with their patients.18 In the study, percent revenue from Medicaid, a joint program between the federal and state governments covering low-income families providing health care benefits to nearly 50 million Americans, had a significant negative impact on quality of care. Previous research has shown a significant difference in quality of care received by patients enrolled in Medicaid-managed care and commercial-managed care.19 This difference has been attributed to factors such as nature of population served, access to care, and pattern of care seeking and adherence to care. Physicians have been very critical of low Medicare reimbursement rates, especially when compared with Medicaid. In 2008, the average Medicare-to-Medicaid fee ratio was around 0.66.20 But the recent passage of the PPACA may affect the results. Under this legislation, Medicaid rates are scheduled to go on par with Medicare payment rates in 2013-2014. In 2013, Medicare enrollees will have access to free preventive care services. In 2014, Medicaid will be expanded to cover adults who earn up to 133% of the federal poverty level. This will result in an additional 20 million people be covered under Medicaid. Past research has indicated that the proportion of uninsured adults in a community impacts quality of care.21 Future research needs to examine how these changes caused by the
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Antecedents of Care by Physicians PPACA impact quality of care provided by physicians. The type of practice significantly impacted quality of care. In an analysis of data not presented in the article, physicians working in practices with 2 or less physicians reported the highest quality care. In addition, physicians with groups of 3 or more physicians and health maintenance organization physicians reported higher than average quality care. On the other hand, physicians working for medical schools, hospitals, and othersreported lower than average quality care to all patients. A study conducted by the Center for Studying Health System Change22 reported that there has been a gradual shift of physicians from solo and 2-physician practices to larger single-specialty practices and hospitals. Accenture, a global management consulting firm, recently conducted a study of changes in physician employment in the United States.23 In their report, they state that only 1 in 3 physicians in the United States will be independent by 2013. The report indicates that unlike those in private practice, employment with health care systems offers physicians various benefits including liberation from financial and business responsibilities, convenient work weeks, and greater access to latest technology. In 2001, the Institute of Medicine’s Committee on Quality of Health Care in America released a report titled, Crossing the Quality Chasm: A New Health System for the 21st Century.24 The report identified the import role of health IT on improving quality of health care in the United States. In 2009, Vice President Joe Biden announced the availability of nearly $1.2 billion in grants for wider use of electronic health records by doctors and hospitals. The American Recovery and Reinvestment Act of 2009 further provided $25 billion in incentives to use electronic health records. In this study, whereas use of IT in clinical practice and prescriptions did not significantly impact quality of care, the use of IT for patient information had a significant positive impact on quality of care. This suggests that physicians can improve quality of care by using IT for activities such as accessing patient notes,
43
ordering diagnostic tests, viewing results of diagnostic tests, and exchanging clinical data and images with other physicians, hospitals, and laboratories. Unfortunately, the correlation results also suggest that older physicians are less likely to use IT in clinical practice, patient information, or prescriptions. According to a study of physicians by Accenture, 2 often mentioned hurdles to health technology are physician resistance and incentive for sharing information in a competitive system.25 Among demographic variables investigated in this study, only income of physician impacted quality of care. Age, gender, and race/ethnicity had no impact on quality of care.
CONCLUSIONS Despite spending more than $2 trillion on health care, quality of care remains a major issue in any health care debate. This study’s findings indicate that allowing physicians to spend adequate time with their patients can have a major impact on the quality of care. Physicians who are paid well and are satisfied with their careers are more likely to provide high-quality care. The use of IT in clinical practice or prescriptions did not significantly impact quality of care provided by physicians. On the other hand, the use of IT for patient information had a significant, positive impact on quality of care. The lack of progress in addressing the medical malpractice crisis in the United States is impacting the quality of care provided by physicians. Although certain provisions of the PPACA, such as parity between Medicaid and Medicare rates in 2013-2014 and allowing Medicare enrollees to access to free preventive care services, may raise quality of care, it would further stress an overworked primary care market. Finally, the recent trend in physicians moving from private practice to employment with health care systems may impact the quality of care. Future research needs to examine if these trends exist in other health care providers such as nurses and practitioners. In addition, future research also needs to study the impact of PPACA on care quality once it goes into full effect in 2014.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
44
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
REFERENCES 1. Partnership for Sustainable Health Care. Strengthening Affordability and Quality in America’s Health Care System. April 2013. http://www.rwjf.org/content/ dam/farm/reports/reports/2013/rwjf405432. Accessed July 23, 2013. 2. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76:517-563. 3. Miller RH, Luft HS. Managed care plan performance since 1980: a literature analysis. JAMA. 1994;271: 1512-1519. 4. Jencks SM, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;284: 1670-1676. 5. McGlynn EA, Asch SM, Adams JL, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. 6. Deshpande SP, de Mello J. An empirical investigation of factors influencing career satisfaction of primary care physicians. J Am Board Fam Med. 2010;23(6): 762-769. 7. AMA-RFS Issue Brief. Support for Graduate Medical Education. http://www.ama-assn.org/resources/doc/ rfs/shortage.pdf. Accessed July 23, 2013. 8. Novak S. Luring students into family medicine. N Y Times. September 9, 2012. http://www.nytimes.com/ 2012/09/10/us/10iht-educlede10.html. Accessed July 23, 2013. 9. Report to the Congress: promoting greater efficiency in Medicare. Medicare Payment Advisory Commission. June 2007. http://www.medpac.gov/chapters/jun07_ ch05.pdf. Accessed June 25, 2013. 10. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428. http://www.nejm.org/doi/full/10.1056/NEJMsa 0803563#t=article. 11. Health Tracking Physician Survey, 2008 (United States) [computer file]. Center for Studying Health System Change. ICPSR27202-v1. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor]; 2010. 12. de Jonge V, Sint Nicolaas J, van Leerdam ME, Kuipers EJ. Overview of the quality assurance movement in health
13. 14. 15.
16.
17. 18.
19.
20.
21.
22.
23.
24.
25.
care. Best Pract Res Clin Gastroenterol. 2011;25(3): 337-347. Dugdale DC, Epstein R, Pantilat SZ. J Gen Intern Med. 1999;14(suppl 1):S34-S40. 2007 Survey of Physicians 50 to 65 Years Old. Irving, TX: Merritt Hawkins and Associates; 2007. de Voe J, Fryer GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract. 2002;51:223-228 [MEDLINE]. Mello MM, Studdert DM, des Roches CM, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff. 2004;23:442-453. DeMello J, Deshpande SP. Career satisfaction of psychiatrists. Psychiatric Services. 2011;62:1013-1018. Manner PA. Practicing defensive medicine—not good for patients or physicians. AAOS Now. 2007. http:// www.aaos.org/news/bulletin/janfeb07/clinical2.asp. Landon BE, Schneider EC, Normand ST. Quality of care in Medicaid managed care and commercial health plans. JAMA. 2007;298:1674-1681. Zuckerman S, Williams AF, Stockley KE. Trends in Medicaid physician fees, 2003-2008, Health Affairs ( Web Exclusive). 2009:w510-w519. Pagan JA, Balasubramanian L, M V. Pauly Physicians’ career satisfaction, quality of care and patients’ trust: the role of community uninsurance. Health Econ Policy Law. 2007;2:347-362. Liebhaber A, Grossman JM. Physicians moving to midsized, single-specialty practices. Community Tracking Study, Center for Studying Health System Change. 2007:1. Tracking Report No. 18. Clinical transformation: dramatic changes as physician employment grows. Accenture http://www.accenture .com/SiteCollectionDocuments/PDF/Accenture_Clinical_ Transformation.pdf. Accessed April 18, 2012. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2001. The electronic healthcare curve where the US stands in connected health technology. Accenture. http://www .accenture.com/SiteCollectionDocuments/PDF/AccentureHealth-Electronic-Healthcare-Curve.pdf#zoom=50. Accessed June 25, 2013.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Antecedents of Care by Physicians Satish P. Deshpande, PhD; Samir S. Deshpande The objective of this study was to examine factors impacting physicians’ quality of care. This study used the Center for Studying Health System Change’s 2008 Health Tracking Physician Survey data set consisting of 4720 physicians belonging to the American Medical Association. Regression analysis indicated that time with patient, career satisfaction, use of information technology for patient information, and income had a significant, positive impact on perception of high-quality care by physicians. Threat of malpractice lawsuits, percent revenue from Medicaid, and type of practice had a significant negative impact on perception of high-quality care by physicians. Among all the variables examined in our study, time with patient had the greatest impact on perception of high-quality care by physicians. Key words: health care, physicians, quality care
A
LTHOUGH THE US economy spends billions of dollars to support the health care system, questions are still raised on the consistency of quality of care for patients.1-5 Betterquality care can save the US economy nearly $400 billion a year in health care costs.6 One of the aims of the Patient Protection and Affordable Care Act (PPACA) signed into law by President Barack Obama on March 23, 2010, was to reduce health care costs while maintaining the standard of care. Among other things, it capped out-of-pocket expenses, fully covered preventive care, created insurance exchanges to make private insurance affordable, and banned insurance companies from denying insurance coverage due to preexisting medical conditions. In addition, it enabled organizations such as the Centers for Medicare & Medicaid Services to set up individual measures to assess quality of new programs. The expansion of PPACA in 2014 is expected to make the existing shortage of doctors,
Author Affiliations: Department of Management, Western Michigan University (Dr S.P. Deshpande), and Department of Chemistry, Kalamazoo College (Mr S.S. Deshpande), Kalamazoo, Michigan.
especially primary care physicians, worse. In addition, nearly one-third of the current physicians are expected to retire within the next 2 decades. The American Medical Association expects the shortage of doctors across all specialties to reach 130 000 by 2025.7 This is despite any additional doctors expected to enter the profession because of expanded enrollments in current medical schools and a gradual increase in the number of new medical schools in the United States. In addition, less than 20% of medical school graduates are expected to end up working in primary care.8 Clearly, this legislation will put additional stress on a health care system where long office waits have become the norm. The purpose of this research was to examine factors that impact the ability of a physician to provide quality care to his or her patients. A better health system can be achieved only if patients have access to reliable, high-quality care. Unreliable or inadequate treatment often leads to unnecessary hospitalization or even death. For example, research has found that nearly $17 to $19 billion in additional Medicare spending takes place because of unplanned and unnecessary hospitals readmissions.9,10 In addition, better quality and safety could save nearly 90 000 lives a year.6
The authors report no conflicts of interest. Correspondence: Satish P. Deshpande, PhD, Department of Management, Western Michigan University, Kalamazoo, MI 49008-5429 ([email protected]). DOI: 10.1097/01.HCM.0000440622.39514.44
METHODS Data The data for this research investigation came from the first round of the Health Tracking
38
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Antecedents of Care by Physicians Physician Survey (HTPS) conducted between February and October 2008.11 The Center for Studying Health System Change is a Washington, DC–based organization founded in 1995 by the Robert Wood Johnson Foundation. It is well known for conducting detailed independent surveys to recognize trends in the US health care system. The objective of Center for Studying Health System Change is to be a resource for health care policy decision makers. It does not take a position on any specific health care policy. Documentation on the survey and public-use data was obtained through the InterUniversity Consortium for Political and Social Research at http://www.icpsr.umich.edu/icpsrweb/ HMCA/studies/27202. The 2008 HTPS replaced the 1996-1997, 1998-1999, 2000-2001, and 2004-2005 Community Tracking Study Physician Surveys. Whereas the Community Tracking Study focused on 60 nationally representative communities, HTPS is a nationally representative sample of American Medical Association physicians. The HTPS Methodology Report at http://www.hschange.com/ CONTENT/1085/1085.pdf provides detailed information on study design, sampling, stratification process, data management, and data collection procedures used in this survey. This survey collected information on a variety of topics including career satisfaction, physician time allocation, use of health information technology (IT), and physicians’ perception of their ability to deliver care. The HTPS data set consists of 4720 physicians who provided direct patient care for at least 20 hours per week. It does not include federal employees, graduates of foreign medical schools who were only temporarily licensed to practice in the United States, residents, interns, and fellows. Listwise deletion of missing values left a sample of 4061 physicians for the study. Dependent variable The dependent variable was based on the following item on the survey, ‘‘It is possible to provide high-quality care to all my patients.’’ This item was measured on a 5-point scale ranging from ‘‘strongly agree’’ (5) to ‘‘strongly disagree’’ (1).
39
Independent variables Time with patient was measured by asking the physicians about their agreement with the statement that they had adequate time to spend with patients during their office visits. The 5-point scale used to measure time with patient ranged from ‘‘strongly agree’’ (5) to ‘‘strongly disagree’’ (1). Threat of malpractice was measured using the following items: they were concerned that they will be involved in a malpractice case sometime in the next 10 years, they felt pressure in their day-to-day practice by threat of malpractice litigation, they ordered tests or consultations to avoid appearance of malpractice, they asked for a consultation to reduce risk of being sued, and they rely less on clinical judgment rather than technology to make a diagnosis because of threat of malpractice lawsuit. These items were also measured on a 5-point scale (5 = strongly agree, 1 = strongly disagree). Career satisfaction was measured using the following item, ‘‘Thinking very generally about your satisfaction with your overall career in medicine, would you say that you are currently very dissatisfied (1), somewhat dissatisfied (2), neither satisfied nor dissatisfied (3), somewhat satisfied (4), or very satisfied (5)?’’ The 2 independent variables, percent practice revenue from Medicare and percent practice revenue from Medicaid, were coded on a 5-point categorical scale (1 = 0%, 2 = 1%-25%, 3 = 26%-50%, 4 = 51%-75%, and 5 = 76%%-100% ). The physician’s practice type was categorized into 1 of the following 6 classifications: 1 = solo/2 physicians, 2 = group of 3 or more physicians, 3 = health maintenance organization, 4 = medical school, 5 = hospital-based physicians, and 6 = other. The data set classified physicians as either primary care physicians (1) or nonprimary care physicians. Physicians in the specialty areas of internal medicine, family medicine or general medicine, and pediatrics were classified as primary care physicians (1). Use of IT in clinical practice, use of IT for patient information, and use of IT for prescriptions were measured on the following scale: 3 = IT available and used, 2 = IT available and not used, 1 = IT not available. Use of IT in clinical practice was measured using 6 items
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
40
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
that covered use of IT for obtaining recommended guidelines, decision support for diagnostic and treatment recommendations, generating reminders for clinicians about preventive services, generating reminders for other needed patient follow-up, generating reminders to patients about preventive services, and e-mailing patients about clinical issues. Use of IT in prescriptions was measured using 4 items that examined use of IT to obtain information on potential patient drug interactions, obtain information on formularies, write prescriptions, and transmit prescriptions to pharmacy. Use of IT in patient information was measured using 6 items that examined the use of IT to access patient notes, order diagnostic tests, view results of diagnostic tests, exchange clinical data and images with other physicians, exchange clinical data and images with hospitals and laboratories, and access information on patients’ preferred language. Overall use of IT was a constrict that consisted of all 16 IT usage–related variables. The data set also measured various demographic variables such as age (1 = 1940 or earlier, 2 = 1941-1945, 3 = 1946-1950, 4 = 1951-1955, 5 = 1956-1960, 6 = 1961-1965, 7 = 1966-1970, 8 = 1971 or later), sex (1 = male, 0 = female), experience (8 = 2005 or later, 7 = 2001-2004, 6 = 1996-2000, 5 = 1991-1995, 4 = 1986-1990, 3 = 1981-1985, 2 = 1976-1980, 1 = 1975 or earlier), race (1 = Hispanic, 2 = white, 3 = black, 4 = Asian or Pacific Islander, 5 = other/mix), and income (6 = more than $300 000, 5 = $250 001 to $300 000, 4 = $200 001 to $250 000, 3 = $150 001 to $200 000, 2 = $100 001 to $150 000, 1 = less than $100 000). More information and the variables used in this study are available at http://www.icpsr.umich.edu/icpsrweb/HMCA/ studies/27202. Statistical analysis Statistical analysis was done using SPSS PASW Statistics 18.0 (SPSS Inc, Chicago, Illinois). First calculated were the means and SDs of all the variables used in this study; next, we calculated the zero-order correlations among the variables. Cronbach’s of construct variables (threat of malpractice, use of IT in clinical practice, use of IT for patient information, and use of IT for
prescriptions) were then calculated. Last was ordinary-least-square regression analysis to examine the impact of our independent variables on our dependent variable and calculate the overall R 2 value of the model.
RESULTS Descriptive statistics of the variables used in this study are presented in Table 1. An average physician ‘‘somewhat agreed’’ with the statement that it was possible for the physician to provide high-quality care to patients. Forty percent of the respondents were primary care physicians. An average physician was a white non-Hispanic male who was born between 1956 and 1960 and had an annual compensation between $150 000 and $200 000. Reliabilities of the construct variables are presented on the diagonal of Table 2. Cronbach’s for threat of malpractice, use of IT in clinical practice, use of IT for patient information, and use of IT for prescriptions were .89, .77, .76, and .82 respectively. Table 2 also presents zeroorder intercorrelations among the variables. Correlation coefficients in Table 2 indicate that there was a linear relationship between a number of independent variables and our dependent variables. But correlation outcomes must be inferred with caution, particularly when Table 1. Descriptive Statistics of the Variables Variables
Mean
SD
n
High-quality care 3.93 1.16 4061 Time with patient 3.46 1.35 4061 Threat of malpractice 3.62 1.02 4061 Career satisfaction 4.03 1.09 4061 Percent revenue from Medicare 30.78 22.65 4061 Percent revenue from Medicaid 16.42 20.13 4061 Type of practice 2.40 1.51 4061 Primary care physician 0.40 0.49 4061 Use of IT in clinical practice 1.89 0.59 4061 Use of IT for patient information 1.99 0.67 4061 Use of IT for prescriptions 1.96 0.71 4061 Age 4.97 1.95 4061 Male 0.74 0.44 4061 Race/ethnicity 2.31 0.82 4061 Income of physician 3.48 1.68 4061 Abbreviation: IT, information technology.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
41
Abbreviation: IT, information technology. Correlations 0.03, 0.04, 0.03, and 0.04 significant at P .05; correlations greater than 0.05 and less than
0.05 significant at P .01. Reliabilities are on the diagonal in parenthesis.
1.00 1.00 0.06 1.00 0.09 0.30 1.00 0.22 0.09 0.00 (0.76) 0.12 0.04 0.02 0.01 (0.82) 0.63 0.15 0.01 0.03 0.11 (0.77) 0.54 0.59 0.12 0.03 0.05 0.00 1.00 0.08 0.03 0.08 0.08 0.14 0.05 0.41 1.00 0.08 0.08 0.24 0.14 0.14 0.09 0.00 0.02 1.00 0.35 0.06 0.04 0.09 0.05 0.06 0.11 0.07 0.15 1.00 0.21 0.06 0.08 0.02 0.02 0.03 0.05 0.14 0.03 0.12 1. High-quality care 2. Time with patient 3. Threat of malpractice 4. Career satisfaction 5. Percent revenue Medicare 6. Percent revenue Medicaid 7. Type of practice 8. Primary care physicians 9. Use IT in clinical practice 10. Use IT for patient info 11. Use IT for prescriptions 12. Age 13. Male 14. Race/ethnicity 15. Income of physician
1.00 0.55 0.18 0.30 0.01 0.08 0.12 0.09 0.00 0.00 0.03 0.10 0.05 0.00 0.10
1.00 0.24 0.29 0.02 0.04 0.11 0.11 0.03 0.07 0.09 0.15 0.04 0.04 0.01
(0.89) 0.21 0.10 0.07 0.03 0.05 0.01 0.02 0.01 0.10 0.09 0.03 0.12
1.00 0.07 0.01 0.03 0.01 0.06 0.04 0.03 0.03 0.01 0.00 0.11
8 7 6 5 4 3 2 1
Table 2. Correlations Among the Variables (n = 4061)
9
10
11
12
13
14
15
Antecedents of Care by Physicians
ascertaining causative relationships. Significant correlation coefficients do not indicate causation because a superficial correlation may exist because of the impact of a third variable on the 2 variables being investigated. In our sample, we notice that a number of independent variables are significantly intercorrelated. Thus, a better test to examine the impact of independent variables on the dependent variable is regression analysis. Regression analysis results are presented in Table 3. Time with patient, career satisfaction, use of IT for patient information, and income had a significant positive impact on perception of high-quality care by physicians. Threat of malpractice lawsuits, percent revenue from Medicaid, and type of practice had a significant negative impact on perception of high-quality care by physicians. Among all the variables examined in our study, time with patient had the greatest impact on perception of high-quality care by physicians. DISCUSSION Although the American medical system has some of the best medical treatment available Table 3. Ordinary Least Squares Regression Results Variables
t
Time with patient .49 a 34.70 Threat of malpractice .04 a 3.31 Career satisfaction .14 a 10.19 Percent revenue from Medicare .01 0.81 Percent revenue from Medicaid .03 b 2.26 Type of practice .08 a 5.37 Primary care physician .00 0.25 Use of IT in clinical practice .01 0.72 a 3.66 Use of IT for patient information .07 Use of IT for prescriptions .02 0.85 Age .01 1.08 Male .00 0.02 Race/ethnicity .02 1.17 Income .07 a 4.68 F 148.01 a R2 0.34 0.34 Adjusted R2 n 4061 Abbreviation: IT, information technology. a P .01. b P .05.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
42
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
in the world, it often fails to provide consistent high-quality care to all its citizens. More than 95 000 deaths per year occur in the United States due to medical error.12 A number of factors such as growing demand for health care, aging population, and variation in treatment have put quality of health care in the national spotlight. In this study, time with patients was the biggest predictor of quality care by physicians. Besides lower quality of care, inadequate time with patients also has been shown to negatively impact health care outcomes such as patient satisfaction, trust, and malpractice claims.13 Our study suggests that older physicians are significantly more likely to spend more time with their patients than younger physicians (r = 0.15). Merritt Hawkins and Associates in their survey of older physicians report that 68% of physicians between 50 and 65 years of age perceive physicians coming out of training today to be less dedicated and hardworking than them when they came out of training.14 In addition, 3 of 4 older physicians report ‘‘patient interaction as the single greatest source of professional satisfaction.’’14 On the other hand, it is also possible that older physicians are closer to retirement, are more likely to work part-time, reduce the number of patients they see, stop accepting new patients, and are less influenced by payment plans where compensation is tied to the number of patients seen. Future research needs to examine the impact of age and other potential factors that could influence the amount of time spent by physicians with patients. Career satisfaction of physicians had a significant positive impact on perceived quality of care. Thus, understanding the causes of dissatisfaction is important, as it can help increase quality of patient care. Previous research has identified a number of factors that can influence career dissatisfaction, including physician autonomy, financial constraints of managed care, ownership in practice, and the ability to make clinical decisions.15 In addition, satisfied physicians have been shown to provide better attention to their patients and less likely to adopt risky prescription practices.16 The threat of malpractice lawsuits had a significant, negative impact on quality of care by
physicians. The threat of malpractice lawsuits has given rise to defensive medical practices by physicians, where physicians order unnecessary or excessive tests and procedures to protect themselves from lawsuits.17 Threat of malpractice lawsuits impacts quality of care in various ways: first, it results in physicians adopting highly aggressive treatments in low-risk conditions; second, it increases the cost of delivery of care because of defensive medication—it is estimated that nearly $60 billion are spent on defensive medication in the United States every year; third, it creates a shortage of physician in highly litigious states encouraging migration of physicians to less litigious states; fourth, it also has an impact on the supply of physicians in specialties such as obstetrics and gynecology, which are more likely to be sued. Finally, it makes physicians less ‘‘candid’’ and more ‘‘hardnosed’’ with their patients.18 In the study, percent revenue from Medicaid, a joint program between the federal and state governments covering low-income families providing health care benefits to nearly 50 million Americans, had a significant negative impact on quality of care. Previous research has shown a significant difference in quality of care received by patients enrolled in Medicaid-managed care and commercial-managed care.19 This difference has been attributed to factors such as nature of population served, access to care, and pattern of care seeking and adherence to care. Physicians have been very critical of low Medicare reimbursement rates, especially when compared with Medicaid. In 2008, the average Medicare-to-Medicaid fee ratio was around 0.66.20 But the recent passage of the PPACA may affect the results. Under this legislation, Medicaid rates are scheduled to go on par with Medicare payment rates in 2013-2014. In 2013, Medicare enrollees will have access to free preventive care services. In 2014, Medicaid will be expanded to cover adults who earn up to 133% of the federal poverty level. This will result in an additional 20 million people be covered under Medicaid. Past research has indicated that the proportion of uninsured adults in a community impacts quality of care.21 Future research needs to examine how these changes caused by the
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Antecedents of Care by Physicians PPACA impact quality of care provided by physicians. The type of practice significantly impacted quality of care. In an analysis of data not presented in the article, physicians working in practices with 2 or less physicians reported the highest quality care. In addition, physicians with groups of 3 or more physicians and health maintenance organization physicians reported higher than average quality care. On the other hand, physicians working for medical schools, hospitals, and othersreported lower than average quality care to all patients. A study conducted by the Center for Studying Health System Change22 reported that there has been a gradual shift of physicians from solo and 2-physician practices to larger single-specialty practices and hospitals. Accenture, a global management consulting firm, recently conducted a study of changes in physician employment in the United States.23 In their report, they state that only 1 in 3 physicians in the United States will be independent by 2013. The report indicates that unlike those in private practice, employment with health care systems offers physicians various benefits including liberation from financial and business responsibilities, convenient work weeks, and greater access to latest technology. In 2001, the Institute of Medicine’s Committee on Quality of Health Care in America released a report titled, Crossing the Quality Chasm: A New Health System for the 21st Century.24 The report identified the import role of health IT on improving quality of health care in the United States. In 2009, Vice President Joe Biden announced the availability of nearly $1.2 billion in grants for wider use of electronic health records by doctors and hospitals. The American Recovery and Reinvestment Act of 2009 further provided $25 billion in incentives to use electronic health records. In this study, whereas use of IT in clinical practice and prescriptions did not significantly impact quality of care, the use of IT for patient information had a significant positive impact on quality of care. This suggests that physicians can improve quality of care by using IT for activities such as accessing patient notes,
43
ordering diagnostic tests, viewing results of diagnostic tests, and exchanging clinical data and images with other physicians, hospitals, and laboratories. Unfortunately, the correlation results also suggest that older physicians are less likely to use IT in clinical practice, patient information, or prescriptions. According to a study of physicians by Accenture, 2 often mentioned hurdles to health technology are physician resistance and incentive for sharing information in a competitive system.25 Among demographic variables investigated in this study, only income of physician impacted quality of care. Age, gender, and race/ethnicity had no impact on quality of care.
CONCLUSIONS Despite spending more than $2 trillion on health care, quality of care remains a major issue in any health care debate. This study’s findings indicate that allowing physicians to spend adequate time with their patients can have a major impact on the quality of care. Physicians who are paid well and are satisfied with their careers are more likely to provide high-quality care. The use of IT in clinical practice or prescriptions did not significantly impact quality of care provided by physicians. On the other hand, the use of IT for patient information had a significant, positive impact on quality of care. The lack of progress in addressing the medical malpractice crisis in the United States is impacting the quality of care provided by physicians. Although certain provisions of the PPACA, such as parity between Medicaid and Medicare rates in 2013-2014 and allowing Medicare enrollees to access to free preventive care services, may raise quality of care, it would further stress an overworked primary care market. Finally, the recent trend in physicians moving from private practice to employment with health care systems may impact the quality of care. Future research needs to examine if these trends exist in other health care providers such as nurses and practitioners. In addition, future research also needs to study the impact of PPACA on care quality once it goes into full effect in 2014.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
44
THE HEALTH CARE MANAGER/JANUARY–MARCH 2014
REFERENCES 1. Partnership for Sustainable Health Care. Strengthening Affordability and Quality in America’s Health Care System. April 2013. http://www.rwjf.org/content/ dam/farm/reports/reports/2013/rwjf405432. Accessed July 23, 2013. 2. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76:517-563. 3. Miller RH, Luft HS. Managed care plan performance since 1980: a literature analysis. JAMA. 1994;271: 1512-1519. 4. Jencks SM, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;284: 1670-1676. 5. McGlynn EA, Asch SM, Adams JL, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. 6. Deshpande SP, de Mello J. An empirical investigation of factors influencing career satisfaction of primary care physicians. J Am Board Fam Med. 2010;23(6): 762-769. 7. AMA-RFS Issue Brief. Support for Graduate Medical Education. http://www.ama-assn.org/resources/doc/ rfs/shortage.pdf. Accessed July 23, 2013. 8. Novak S. Luring students into family medicine. N Y Times. September 9, 2012. http://www.nytimes.com/ 2012/09/10/us/10iht-educlede10.html. Accessed July 23, 2013. 9. Report to the Congress: promoting greater efficiency in Medicare. Medicare Payment Advisory Commission. June 2007. http://www.medpac.gov/chapters/jun07_ ch05.pdf. Accessed June 25, 2013. 10. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428. http://www.nejm.org/doi/full/10.1056/NEJMsa 0803563#t=article. 11. Health Tracking Physician Survey, 2008 (United States) [computer file]. Center for Studying Health System Change. ICPSR27202-v1. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor]; 2010. 12. de Jonge V, Sint Nicolaas J, van Leerdam ME, Kuipers EJ. Overview of the quality assurance movement in health
13. 14. 15.
16.
17. 18.
19.
20.
21.
22.
23.
24.
25.
care. Best Pract Res Clin Gastroenterol. 2011;25(3): 337-347. Dugdale DC, Epstein R, Pantilat SZ. J Gen Intern Med. 1999;14(suppl 1):S34-S40. 2007 Survey of Physicians 50 to 65 Years Old. Irving, TX: Merritt Hawkins and Associates; 2007. de Voe J, Fryer GE, Hargraves JL, Phillips RL, Green LA. Does career dissatisfaction affect the ability of family physicians to deliver high-quality patient care? J Fam Pract. 2002;51:223-228 [MEDLINE]. Mello MM, Studdert DM, des Roches CM, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff. 2004;23:442-453. DeMello J, Deshpande SP. Career satisfaction of psychiatrists. Psychiatric Services. 2011;62:1013-1018. Manner PA. Practicing defensive medicine—not good for patients or physicians. AAOS Now. 2007. http:// www.aaos.org/news/bulletin/janfeb07/clinical2.asp. Landon BE, Schneider EC, Normand ST. Quality of care in Medicaid managed care and commercial health plans. JAMA. 2007;298:1674-1681. Zuckerman S, Williams AF, Stockley KE. Trends in Medicaid physician fees, 2003-2008, Health Affairs ( Web Exclusive). 2009:w510-w519. Pagan JA, Balasubramanian L, M V. Pauly Physicians’ career satisfaction, quality of care and patients’ trust: the role of community uninsurance. Health Econ Policy Law. 2007;2:347-362. Liebhaber A, Grossman JM. Physicians moving to midsized, single-specialty practices. Community Tracking Study, Center for Studying Health System Change. 2007:1. Tracking Report No. 18. Clinical transformation: dramatic changes as physician employment grows. Accenture http://www.accenture .com/SiteCollectionDocuments/PDF/Accenture_Clinical_ Transformation.pdf. Accessed April 18, 2012. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2001. The electronic healthcare curve where the US stands in connected health technology. Accenture. http://www .accenture.com/SiteCollectionDocuments/PDF/AccentureHealth-Electronic-Healthcare-Curve.pdf#zoom=50. Accessed June 25, 2013.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
