Physician Adaptation to Health Maintenance Organizations and Implications for Management Rockwell Schulz, William E. Scheckler, M.D., Chris Girard, and Kristin Barker The growth of health maintenance organizations (HMOs) and other forms of managed care presents a challenge to traditional patterns of private practice. In Dane County, Wisconsin (Madison Metropolitan Area), the proportion of the population enrolkd in closed-panel HMOs increased dramatically, from 10 percent in 1983 to over 40 percent by 1986. This study surveyed 850 practicing physicians regarding their expectations before, and experiences after this rapid change to competitive HMOs. Although most physicians expected a loss of earnings and lower-quality care, the majority reported that neither declined. However, most physicians expected and reported a decline in their autonomy. Primary care physicians were most supportive of the change to HMOs. The implications of these findings for management practices are discussed.
Funding for this project has, in part, been provided by Wisconsin Institute of Family Medicine; the University of Wisconsin Departments of Family Medicine and Practice, Internal Medicine, and Employee Benefits; Vice Chancellor's Office-Center for Health Sciences; Dane County Medical Society; Wisconsin State Medical Society; Madison General Hospital Foundation; Group Health Cooperative of South Central Wisconsin; and various State of Wisconsin agencies, including the Departments of Administration, Health and Social Services, Industry, Labor and Human Relations, Employee Trust Funds, and Office of Insurance Commissioner. Address correspondence and requests for reprints to Rockwell Schulz, Ph.D., Professor, Department of Preventive Medicine, Bradley Memorial, University of Wisconsin, 1300 University Avenue, Madison, WI 53706. William E. Scheckler, M.D., is Professor, Department of Family Medicine and Practice and Department of Medicine; Chris Girard, Ph.D. is Postdoctoral Fellow, Departments of Sociology and Psychiatry; Kristin Barker, M.A., is a doctoral student in the Department of Sociology.
44
HSR: Health Services Research 25:1 (April 1990, Part I)
With only 11 percent of the population in the United States currently enrolled in HMOs (Interstudy 1987), most physicians are not yet directly affected by HMO development. Even physicians who participate in HMOs, such as those in open-panel plans with few controls (Burkett 1982), may not have felt a direct impact on their practice. Nonetheless, there is considerable anxiety about HMO development among physicians. HMOs are growing, and many physicians believe that the fee-for-service (FFS) system will disappear (California Medical Association [CMA] 1986). Fearing the potentially adverse consequences of HMOs - such as loss of clinical autonomy, a decline in quality of care, restrictions on referrals, and loss of income - physicians are organizing against HMOs (Meyer 1987). HMOs are considered part of the phenomenon of "managed care." By definition, patient care that is managed by an organization suggests less clinical autonomy (Fielding 1984). There is also evidence that physician incomes in HMOs are less than those in FFS, although incomes in HMOs may be comparable relative to workloads (Luft 1981). Moreover, despite empirical evidence that quality of care in HMOs is not necessarily lower than in FFS (Luft 1981; Hornbrook and Berki 1985; Cunningham and Williamson 1980), recent surveys suggest that two-thirds to three-quarters of physicians believe that quality of care in HMOs is inferior to FFS (CMA 1986; Taylor and Kagay 1986). Previous experience suggests that once major changes in the health care delivery system are implemented, the initial resistance of physicians to such changes may be moderated considerably. For example, Colombotos and Kirchner (1986) report that before the enactment of Medicare only 38 percent of private practitioners were in favor of the proposed system; just six months after the program went into effect, 81 percent said they were "in favor." Nevertheless, physician resistance to HMOs remains strong. This creates a major challenge for managers of HMOs, particularly when physicians perceive joining an HMO as a "necessary evil" (Brown 1983). Anderson, Herold, Butler, et al. (1985) suggest that physician acceptance of HMOs is greater when physicians are integrated into the community and when their leaders support HMO development. Yet little is known about how physician support for HMOs is affected by specialty area, the type of HMO, actual participation in an HMO, and physician perceptions regarding the effect of HMOs on autonomy, quality of care, and earnings. Although studies have focused on physician adaptation to change (e.g., Colombotos and Kirchner 1986), there is little empirical evidence regarding predictors of physician support for
Physician Adaptation to HMOs
45
HMO development. In communities undergoing a transition from FFS to HMOs, such knowledge is important to HMO managers and health care policymakers confronted with the question: What can be done to facilitate this transition to HMOs? Dane County, Wisconsin has experienced a dramatic transformation in its health services. On December 31, 1983, about 10 percent of the county population was in closed-panel HMOs. The next morning, on January 1, 1984, this proportion dimbed to about 27 percent and, by 1986, it had grown to over 40 percent. This change was precipitated by the State of Wisconsin, which is the dominant employer in Dane County. In response to rising employee health insurance benefit costs, the state in 1982 announced that it was going to adopt direct provider bidding. The state offered to pay 105 percent of the lowest HMO premium bid or 95 percent of the standard FFS plan, whichever was lower. The new system required that state employees pay the difference if they did not accept the low bid plan. Fearful of losing patients to an older staff model plan or to newly emerging HMOs, 85 percent of the physicians in Dane County either helped to form or joined one of five closed-panel HMOs, or associated themselves with a new open-panel plan. A further description of the change, why and how it occurred, and characteristics suggesting the likelihood of its happening elsewhere is available in other publications (Scheckler and Schulz 1987; Friedman 1984). The dramatic nature of the change to HMOs and its occurrence literally overnight provided the opportunity to survey physicians' expectations of the change and their reported experiences two and onehalf years after it happened. Both patients and payers appeared pleased with the change (Scheckler and Schulz 1987; Friedman 1984; Luehrs and Hanson 1984). However, it is the physicians who had to change the most. This is especially true insofar as physicians were essentially forced to adopt an HMO practice after years of FFS practice-an experience quite different from that of physicians who upon completion of training choose to join an HMO. In this article, we address the following questions: first, what did physicians in Dane County expect to be the impact of the change to HMOs on their practice? Did these perceptions change after nearly three years experience with the change? Second, which physicians were most likely to report a decline in earnings, autonomy, and quality, and were least supportive of the change to HMOs? Third, what are some of the variables that may have affected physician support for HMOs? Finally, what are the implications of these findings for managers seeking to gain physician support for HMO development?
46
HSR: Health Services Research 25:1 (April 1990, Part I)
METHODS Dane County had an estimated population of 338,827 in 1985. The county is the metropolitan area for Madison (which includes the state capitol and the University of Wisconsin). There are about 850 practicing physicians in the county. Nearly half of these physicians practice at the University of Wisconsin Hospital and Clinics, and another 27 percent practice in large multisite, multispecialty clinics with more than ten physicians. In 1986, there were five HMOs based in Madison with 10,000 or more Dane County member subscribers (see Table 1). Two open-panel IPAs were also present in 1986, but these IPAs have been excluded from the study because few Dane County physicians were members. We determined that the most accurate way to define physicians in
Table 1: Dane County HMOs Included in 1986 Survey Physicians 122
Number of Subscriber Members* 24,000
69
19,000
350t
65,000
Number of
HMO Model Closed-panel IPA model
Ownership A joint venture among multiple physician groups and solo practitioners, insurance carrier, and a
hospital
Group mnodel Group A
Group B
Staff model University
53 Physician members of a multispecialty group practice 150 Physician members of a multispecialty group practice
A joint venture between the 400 10,000 clinical practice partnership of the faculty, the university hospital and the medical school Staff Subscribers to a nonprofit 21 29,000 cooperative *At least 90 percent of the members of each plan reside in Dane County, except for Group B in which one-third reside outside Dane County. tThis number includes subcontracted primary care groups outside of Dane County.
Physician Adaptation to HMOs
47
active practice was by active hospital medical staff membership. This became evident after comparing licensing board, medical society and hospital staff lists. We included in the study all active staff members from four community hospitals and the university hospital. Physicians practicing at the Veterans Administration hospital and house staff in training programs were excluded. The University of Wisconsin Survey Research Laboratory (WSRL) conducted the physician surveys. Respondent names were coded by WSRL to ensure confidentiality. In October 1983 -after the major HMOs had been formed but before the change to HMOs on January 1, 1984-questionnaires were mailed to physicians to ask about their support for HMO development. The questionnaires specifically asked about the anticipated effect of HMOs on the respondent's own practice and on medical care in the community. In the summer and fall of 1986, a follow-up survey was mailed to 850 physicians in Dane County. This second survey contained questions regarding the impact of HMO development after about two and one-half years experience. Our survey response rates are relatively high when compared to similar studies of physicians, lawyers, and other professionals. The response rate for the 842 physicians in the 1983 sample was 58 percent with only two follow-up surveys. However, the 1983 data are reported only for those doctors who also responded to the 1986 survey. The overall response rate for the 1986 survey was 65 percent. We report findings for all respondents (N = 545) in this larger sample, except when we are making a direct comparison with the 1983 data. In the 1986 survey, response rates exceeded 70 percent for primary care (family practice, general internal medicine, general pediatrics, and general OB/GYN). The response rates were lower for non-primary care referral specialists, university clinicians, and hospital-based specialists: 67 percent, 60 percent, and 54 percent, respectively. Because of a lower response rate, more caution is needed in interpreting results from hospital-based physicians in particular. Although there were five follow-ups to nonresponders in the 1986 survey, there was no evidence of selection bias among slower responders. Physicians who responded only after the third request were not significandy different (p < .10) from prompt responders in age, gender, type of practice, or in responses to study questions. Also, we compared responses before and after HMO development on a subset of 288 physicians who responded to both the 1983 and 1986 surveys. These 288 physicians were not significantly different in age, gender, and type of practice from respondents to the 1986 survey (p < .10),
48
HSR: Health Services Research 25:1 (April 1990, Part I)
although proportionately fewer hospital-based and referral specialists responded to both surveys. Of the 545 usable 1986 responses, by self-report, 152 were in specialties of family practice, internal medicine, OB/GYN, or pediatrics providing basically primary care. Another 316 reported that they were in general surgery, psychiatry, internal medicine, OB/GYN, or one of the subspecialties, and that their practice was mainly referral based. The remaining 75 respondents were hospital based in anesthesiology, emergency medicine, -pathology, or radiology. About 14 percent of the responding physicians were female, and 57 percent were 46 years of age or younger. For most survey items, Likert-type scales were used to measure physician attitudes concerning HMO development and its impact. When asked to assess the effect of HMOs on quality of care and physician autonomy, the doctors themselves were required to interpret what the terms "quality" and "autonomy" actually mean. The survey data were buttressed by three-hour interviews with administrators and medical directors using the "Organizational Structure of HMOs" instrument from the National Center for Health Services Research (1984). This interview schedule included questions concerning how HMOs manage health care and darifying the specific nature of their contractual arrangements with hospitals and hospitalbased specialists. To further validate survey findings, informal interviews concerning the impact of HMOs were conducted with three or more physicians from each HMO and from the group of physicians not joining an HMO. t-Tests are used to test the difference in responses between HMO and FFS settings and between the 1983 and 1986 perceptions. An ordered probit analysis, most appropriate for ordinal-level dependent variables (Winship and Mare 1984), is used to help determine the factors that explain physician support for HMO development.
FINDINGS 1. What was expected and what was the resulting impact on physicians' practices from the change to HMOs? Table 2 reports findings for the subsample of physicians who responded to both the 1983 and 1986 surveys. It shows that for all measures of the impact of HMO development, the reported experience was more favorable than doctors had projected. These differences were most dramatic regarding the actual effect of HMOs on paperwork, earnings,
Q~ ~ zz z z E~~~~~~~eM CC m C1s C
LO
LO ° C oo 'to C q Lo c
co
COC Co co
en
z~
co
_ Co
Co~~~~~~~~V
w
4
Co
- e~~~~~~~ PLi 04
>
C) 0 En
CQ
Co
Lm
nO L
0o O
X
Lo
CoLo
O0
00
L
"0
U:^ U
t1
tM~~ ~ -
~~~~~
~~
LQ__ C, C1U:
_
ena~
Loen
°U
*~ C
N.'0
~
~ ~~
LOC4O -+
~
~
~
"0C1-44
°
O
~
oo4)_
t0-
0
o '-
a)
10-C
~~~~~~
_-
Coq
1
c
a
>' e k 5.5
UbiD
Co~~~~~~~~~~ c
CUv
~~Z4~4~
c
~CoO~~
~
e
a
c
t
U)v o.,C
Physician Adaptation to HMOs
55
satisfied with HMO patients and the percentage satisfied with FFS patients for virtually all categories except the ability to refer. The absence of any difference in satisfaction with HMO patients and satisfaction with FFS patients is found within each of the primary care specialties as well. Finally, for physicians who changed from FFS to more than 10 percent HMO patients, there was a significant difference in satisfaction with HMO and FFS patients only with respect to earnings and ability to refer patients to consultants. Assuming that hospital-based and referral specialists have higher take-home incomes than primary care physicians (Owens 1986), it is interesting that primary care physicians are more satisfied with their incomes than are hospital-based physicians. Indeed, the satisfaction of primary care physicians with HMO incomes is equal to the satisfaction of referral specialists with their income from FFS patients. We also investigated to see if the percentage of HMO patients in a physician's practice (or a physician's presence in an HMO) affected overall work satisfaction or satisfaction with incomes from practice. We found no significant correlation (Pearson's R) between any of these variables. Figure 2 presents the results of an ordered probit analysis of variables affecting the level of support for HMOs among physicians. Possible survey responses consist of five levels of support (very opposed, opposed, neutral, supportive, very supportive). When entered simultaneously in the probit analysis, several variables are significant (p = .01 or better) in predicting a higher level of support for HMOs. These variables are perceptions that HMOs have not reduced the respondent's autonomy as a physician, that HMOs are at least as cost effective as FFS, that the quality of medical care has not been reduced by HMOs, that the respondent has at least 10 percent HMO patients, and that the respondent is in an HMO. When broken down by HMO (see appendix), Group B and the university plan are the most significant predictors of support among HMOs. Additional significant predictors include not being dissatisfied with income received from HMO patients, and being a primary care physician rather than a hospitalbased or referral specialist. The age and sex of the respondent (included in the probit analysis in the appendix) are not significantly associated with level of support for HMOs.
56
HSR: Health Services Research 25:1 (April 1990, Part I)
Figure 2: Results of an Ordered Probit Analysis -Variables Helping to Predict Physician Support for HMO Development No Decline in Autonomy
HMO as Cost
Effective as FFS
No Decline in
Quality
10% or
Not
More HMO Patients
Dissatisfied
In an HMO
In with HMO Primary Income Care
.7
.6
.5
.4
.3
.2
.1
For the purpose of simplified presentation and direct comparison, all explanatory variables have been dichotomized by giving positive and neutral responses a score of 1 and negative responses a score of 0. The heights of the bars are proportional to the probit coefficients, all of which were significant at the .01 level (two-tailed test). Chi-square for this simplified model is 219.2, d.f. = 7, p = .001.
CONCLUSIONS AND IMPLICATIONS In summary, we found that most physicians expected the change to HMOs to result in less autonomy, lower earnings, more paperwork, and lower quality of care. Nevertheless, except for some loss of auton-
Physician Adaptation to HMOs
57
omy, only about one-third reported that such apprehensions materialized. Second, most physicians perceived a loss in autonomy with the development of HMOs. Even most physicians who did not join an HMO reported that their autonomy dedined, presumably because they were limited in traditional referral patterns or were forced into discounted charges. Interestingly, over 84 percent of physicians in Group A reported a decline in autonomy while only 44 percent in Group B reported a decline. Yet, based on interviews in both groups, it was apparent that control procedures over physicians' HMO patients were more rigorous in Group B than in Group A. Perhaps autonomy is more a feeling than a fact. Perceived autonomy may be a function of factors other than actual autonomy - for example, expectations, changes in the status quo, achievement of goals, feelings of control, and earnings that appear to be high when viewed in the context of actual constraints (i.e., the constraints in Dane County HMOs). Third, the majority of physicians reported that their earnings did not decline. This finding is surprising considering that managers of all HMOs said that gross income per patient was substantially less for HMO patients than for FFS patients. Perhaps in the short run at least, growth in patient volume and shifting of expenses to FFS patients and affiliated organizations (such as hospitals and the medical school) can absorb cost savings to HMO patients. However, if the number of HMO patients continues to increase and HMO premium competition continues, opportunities for making up income reductions from HMO patients will decline. Fourth, it is physicians who have had little or no experience with HMOs who are most likely to report that quality has declined. With few exceptions, empirical evidence suggests that quality of care in HMOs is comparable to that of FFS (Luft 1981; Hornbrook and Berki 1985; Cunningham and Williamson 1980). Our findings show that most physicians in Dane County who were treating HMO patients reported that quality of care did not decline with HMO development (although one might not expect a physician to deprecate his or her own service). In light of the overall evidence, it is quite possible that states ments about inferior HMO quality, made by physicians without firsthand experience, are based on fears, not observations. Fifth, except for some frustration regarding their lack of freedom to refer patients at will, primary care physicians appear to be as satisfied treating HMO patients as treating FFS patients. However, referral and hospital-based specialists are significantly less satisfied with HMO patients than with FFS patients. This may be attributable to percep-
58
HSR: Health Services Research 25:1 (April 1990, Part I)
tions of loss of autonomy due to transfer of some power to primary care physicians, who assume a gatekeeper role. Also, loss of autonomy may be attributed to the monitoring function and control assumed by HMO plan managers. Accompanying this loss of autonomy are reports by many subspecialists that referrals have declined. In addition, because HMOs have extracted substantial discounts from subspecialists and hospital-based physicians, these doctors are more likely to express dissatisfaction with HMO patients. It is also noteworthy that primary care physicians, who might experience some strains due to their gatekeeper role, reported no significant difference in satisfaction in their patient relationships with HMO patients versus FFS patients. This is possibly an important finding because of the reported problem of a "more demanding patient" in an HMO (Luft 1981). It should also be noted that in Dane County, Medicaid and general relief patients, who are required to enroll in an HMO, represent as many as 18 percent of the patients in one HMO. Findings from experiences in Dane County suggest that, as with any change in the status quo, unless there is strong demand for change among those who will be most affected by the change, there are fears about the consequences of the change (Dalton 1973). However, results from this survey suggest that most physicians who changed from FFS practices to serving a substantial number of HMO patients did not perceive that the actual change had serious adverse effects. This is a rather remarkable finding considering the magnitude of changes in Dane County in a short period of time. Although some physicians have been hurt by the change and are vocal in their complaints, we can document only eight physicians (fewer than 1 percent) who said that their departure from Dane County or their early retirement was at least in part because of HMO development. Is the Dane County experience atypical of what might be expected of physician responses to HMO development in other communities? For example, our findings are in conflict with a survey in Minnesota that found that most physicians, especially those in the Twin Cities, were unhappy with HMOs (Dombrosk 1988). (However, it should be noted that only 28 percent responded to the Minnesota survey, and that the responses could have been biased toward those who were most disgruntled.) If it is atypical, one difference may be that in Dane County the doctors themselves organized the new HMOs. (Although in some cases the formation of these HMOs initially occurred in partnership with a hospital or insurance carrier, some of these were later excluded from ownership.) Whether or not physicians are treated any better in an HMO they own, they may feel better about an HMO that
Physician Adaptation to HMOs
59
they have helped to develop. A second difference is that physicians in Dane County have been accustomed to practicing in an organized setting. The vast majority of physicians have been in a group practice or medical school. On the other hand, the results show (see appendix) that physicians who were in solo or small group practice and are now in the closed-panel IPA also tend to be supportive of HMO development. Other contributing factors to the successful transformation may be that physicians were conditioned to competition through various clinics, hospitals, and medical school organizations in a community with no physician shortage. Moreover, physicians had previous experience with an HMO through their open-panel medical society IPA. Nevertheless, many of the pre-HMO conditions in Dane County existed in the Twin Cities as well. Furthermore, high HMO penetration has existed longer in the Twin Cities than in Dane County. Perhaps there is a certain life cycle of satisfaction with HMO development. It is also apparent that, as might be expected, HMO development contributes to a shift in influence favoring primary care physicians. In an HMO, primary care physicians have "gatekeeper" controls that are not present in a FFS system. Furthermore, there is evidence of income leveling in some HMOs to the disadvantage of referral and hospitalbased specialists. The change to competitive HMO systems has been a major disruption. The change has resulted in the virtual elimination of independent solo or small group practices. Most of these physicians have had to join or form large multispecialty groups or watch their patient base erode. Consequently, the repercussions of the change from FFS to HMOs may be greater than the change itself. Nevertheless, even with such repercussions, less autonomy, and lower earnings, there is to date little evidence of general disaffection with medical practice in Dane County. We propose that physicians' perceptions about the impact of a change from FFS to HMOs-even after the change occurs-may reflect more how it was accomplished, physicians' roles in effecting it, and physicians' expectations of results than the actual change itself. In the Dane County experience, fears before the change may have cushioned perceptions of actual results. Moreover, in this case, physicians developed their own HMOs to help control their own destinies. For the most part, these HMOs have been successful in retaining the number and types of patients (if not the autonomy and income) to which Dane County physicians are accustomed. What are the implications of these findings for persons seeking physician support for HMO development? We suggest the following:
60
HSR: Health Services Research 25:1 (April 1990, Part I)
1. In recruiting physicians for the HMO, expectations should not be raised beyond what is achievable. Results that are better than expectations facilitate satisfaction (Lawler 1973). According to HMO officials, one of the reasons why physicians in Group A perceived that earnings declined (see Figure 1) was that overexpectations had been created by unrealistically high earnings in the first year. 2. Physicians should be committed to the success of the HMO. Although financial incentives are important in this regard, participation in management can also increase a sense of ownership and organizational commitment. Participation has been found to be a significant predictor of physician satisfaction (Schulz and Schulz 1988; Barr and Steinberg 1983; Nathanson and Becker 1973). 3. Believing that the HMO is cost effective-it is achieving what it is supposed to achieve-appears to be an important predictor of physician support for HMOs. In the case of Dane County, the state believes that HMOs have saved millions of tax dollars (Owens 1986). Subscribers, too, are generally pleased (Scheckler and Schulz 1987), and most Dane County physicians believe that HMOs are cost effective and that quality of care is as high or higher than it was before. HMO leadership needs to ensure that it is, and to make evidence of this available. 4. Although perceptions of autonomy are an important predictor of support, there is preliminary evidence to suggest that perceived autonomy may be a function of participation in management affairs in addition to actual clinical autonomy (Schulz and Schulz 1988). Participation in management information and decisions facilitates a feeling of control over environmental forces. 5. A large number of HMO patients, which is an indicator of the success of the HMO, was also found in our study to be an important predictor of support for HMOs. Physicians repeatedly stated in interviews that the primary motivation for organizing or joining an HMO was to retain patients. Indeed, physicians who did not join an HMO stood to lose over one-third of their patients (Scheckler and Schulz 1987). Presumably, physicians with fewer HMO patients either lost patients or had increasing anxieties about losing them.
Physician Adaptation to HMOs
61
6. It appears that primary care physicians -shown in our study to be the most supportive of HMO development -may provide a bridge for HMO managers seeking to build support among other physicians. 7. Satisfaction with quality of care and income from HMO patients are other factors that account for HMO success and physician support for HMOs. HMO managers should seek to dispel anxiety that quality of care and amount of income will necessarily dedine.
The leadership of HMOs obviously should strive to maintain and improve quality of care, cost effectiveness, earnings, and the autonomy of physicians to practice what they were trained to do. However, success is measured relative to expectations and to perceptions of efforts to achieve expectations. Physicians who share in setting goal expectations, in information on how well the organization is doing, and in decisions to achieve goal expectations are likely to be more satisfied than those who do not (Schulz and Schulz 1988; Barr and Steinberg 1983). Further, physicians thus participating are more likely to perceive that organizational effort is being made to achieve high-quality care (Schulz, Girard, and Harrison 1989). This is still an early chapter in the transformation of health services to HMOs in Dane County. More study is needed on the longerrange effects of this change. However, initial evidence from Dane County suggests that, although physicians may be apprehensive about the change to competitive, closed-panel HMOs, it is possible for these physicians to become generally supportive and satisfied once the change is implemented.
APPENDIX Ordered Probit: Variables Helping to Predict Physician Support for HMO Development (N= 387) Referral specialists Hospital based Percent of patients in HMO HMO model: IPA Group A
Coefficient -.30* -.42t .20** .39t .48t
t
-2.2 -1.7 2.9 1.9 1.9 Continued
62
HSR: Health Services Research 25:1 (April 1990, Part I)
Appendix: Continued Coefficient .65** .66 .51** .53***
t 3.0 1.3 2.6 3.6
Lower quality of care in HMOs
-.49***
-3.9
Level of dissatisfaction with income from HMO patients
1.14***
-3.8
HMOs are less cost effective
-.41***
-4.6
Control variables: Age of physician Sex of physician (male - 1)
-.00 .06
-0.3 0.4
Group B Staff University Reports of no decline in autonomy
Ordered probit threshholds: -6.1 -3.5*** Very supportive/Supportive -4.2 -2.3*** Supportive/Neutral -2.1 -1.2* Neutral/Opposed 0.4 0.2 Opposed/Very opposed -2 x (log likelihood) - 910.4 Chi-Square -256.1 (d.f. = 14, p 10%, 2 10-25 %, 3 = 26-50%, 4 51-75%, 5-76-100%; Quality-i -increase, 2-same, 3-decrease; HMO income-I - very satisfied, 2 = satisfied, 3 - somewhat satisfied, 4 neutral, 5 somewhat dissatisfied, 6 - dissatisfied, 7 very dissatisfied; cost effectiveness of HMOs relative to pre-HMO system -1 more, 2 - same, 3 - less; age -actual age. =
=
=
*p
Funding for this project has, in part, been provided by Wisconsin Institute of Family Medicine; the University of Wisconsin Departments of Family Medicine and Practice, Internal Medicine, and Employee Benefits; Vice Chancellor's Office-Center for Health Sciences; Dane County Medical Society; Wisconsin State Medical Society; Madison General Hospital Foundation; Group Health Cooperative of South Central Wisconsin; and various State of Wisconsin agencies, including the Departments of Administration, Health and Social Services, Industry, Labor and Human Relations, Employee Trust Funds, and Office of Insurance Commissioner. Address correspondence and requests for reprints to Rockwell Schulz, Ph.D., Professor, Department of Preventive Medicine, Bradley Memorial, University of Wisconsin, 1300 University Avenue, Madison, WI 53706. William E. Scheckler, M.D., is Professor, Department of Family Medicine and Practice and Department of Medicine; Chris Girard, Ph.D. is Postdoctoral Fellow, Departments of Sociology and Psychiatry; Kristin Barker, M.A., is a doctoral student in the Department of Sociology.
44
HSR: Health Services Research 25:1 (April 1990, Part I)
With only 11 percent of the population in the United States currently enrolled in HMOs (Interstudy 1987), most physicians are not yet directly affected by HMO development. Even physicians who participate in HMOs, such as those in open-panel plans with few controls (Burkett 1982), may not have felt a direct impact on their practice. Nonetheless, there is considerable anxiety about HMO development among physicians. HMOs are growing, and many physicians believe that the fee-for-service (FFS) system will disappear (California Medical Association [CMA] 1986). Fearing the potentially adverse consequences of HMOs - such as loss of clinical autonomy, a decline in quality of care, restrictions on referrals, and loss of income - physicians are organizing against HMOs (Meyer 1987). HMOs are considered part of the phenomenon of "managed care." By definition, patient care that is managed by an organization suggests less clinical autonomy (Fielding 1984). There is also evidence that physician incomes in HMOs are less than those in FFS, although incomes in HMOs may be comparable relative to workloads (Luft 1981). Moreover, despite empirical evidence that quality of care in HMOs is not necessarily lower than in FFS (Luft 1981; Hornbrook and Berki 1985; Cunningham and Williamson 1980), recent surveys suggest that two-thirds to three-quarters of physicians believe that quality of care in HMOs is inferior to FFS (CMA 1986; Taylor and Kagay 1986). Previous experience suggests that once major changes in the health care delivery system are implemented, the initial resistance of physicians to such changes may be moderated considerably. For example, Colombotos and Kirchner (1986) report that before the enactment of Medicare only 38 percent of private practitioners were in favor of the proposed system; just six months after the program went into effect, 81 percent said they were "in favor." Nevertheless, physician resistance to HMOs remains strong. This creates a major challenge for managers of HMOs, particularly when physicians perceive joining an HMO as a "necessary evil" (Brown 1983). Anderson, Herold, Butler, et al. (1985) suggest that physician acceptance of HMOs is greater when physicians are integrated into the community and when their leaders support HMO development. Yet little is known about how physician support for HMOs is affected by specialty area, the type of HMO, actual participation in an HMO, and physician perceptions regarding the effect of HMOs on autonomy, quality of care, and earnings. Although studies have focused on physician adaptation to change (e.g., Colombotos and Kirchner 1986), there is little empirical evidence regarding predictors of physician support for
Physician Adaptation to HMOs
45
HMO development. In communities undergoing a transition from FFS to HMOs, such knowledge is important to HMO managers and health care policymakers confronted with the question: What can be done to facilitate this transition to HMOs? Dane County, Wisconsin has experienced a dramatic transformation in its health services. On December 31, 1983, about 10 percent of the county population was in closed-panel HMOs. The next morning, on January 1, 1984, this proportion dimbed to about 27 percent and, by 1986, it had grown to over 40 percent. This change was precipitated by the State of Wisconsin, which is the dominant employer in Dane County. In response to rising employee health insurance benefit costs, the state in 1982 announced that it was going to adopt direct provider bidding. The state offered to pay 105 percent of the lowest HMO premium bid or 95 percent of the standard FFS plan, whichever was lower. The new system required that state employees pay the difference if they did not accept the low bid plan. Fearful of losing patients to an older staff model plan or to newly emerging HMOs, 85 percent of the physicians in Dane County either helped to form or joined one of five closed-panel HMOs, or associated themselves with a new open-panel plan. A further description of the change, why and how it occurred, and characteristics suggesting the likelihood of its happening elsewhere is available in other publications (Scheckler and Schulz 1987; Friedman 1984). The dramatic nature of the change to HMOs and its occurrence literally overnight provided the opportunity to survey physicians' expectations of the change and their reported experiences two and onehalf years after it happened. Both patients and payers appeared pleased with the change (Scheckler and Schulz 1987; Friedman 1984; Luehrs and Hanson 1984). However, it is the physicians who had to change the most. This is especially true insofar as physicians were essentially forced to adopt an HMO practice after years of FFS practice-an experience quite different from that of physicians who upon completion of training choose to join an HMO. In this article, we address the following questions: first, what did physicians in Dane County expect to be the impact of the change to HMOs on their practice? Did these perceptions change after nearly three years experience with the change? Second, which physicians were most likely to report a decline in earnings, autonomy, and quality, and were least supportive of the change to HMOs? Third, what are some of the variables that may have affected physician support for HMOs? Finally, what are the implications of these findings for managers seeking to gain physician support for HMO development?
46
HSR: Health Services Research 25:1 (April 1990, Part I)
METHODS Dane County had an estimated population of 338,827 in 1985. The county is the metropolitan area for Madison (which includes the state capitol and the University of Wisconsin). There are about 850 practicing physicians in the county. Nearly half of these physicians practice at the University of Wisconsin Hospital and Clinics, and another 27 percent practice in large multisite, multispecialty clinics with more than ten physicians. In 1986, there were five HMOs based in Madison with 10,000 or more Dane County member subscribers (see Table 1). Two open-panel IPAs were also present in 1986, but these IPAs have been excluded from the study because few Dane County physicians were members. We determined that the most accurate way to define physicians in
Table 1: Dane County HMOs Included in 1986 Survey Physicians 122
Number of Subscriber Members* 24,000
69
19,000
350t
65,000
Number of
HMO Model Closed-panel IPA model
Ownership A joint venture among multiple physician groups and solo practitioners, insurance carrier, and a
hospital
Group mnodel Group A
Group B
Staff model University
53 Physician members of a multispecialty group practice 150 Physician members of a multispecialty group practice
A joint venture between the 400 10,000 clinical practice partnership of the faculty, the university hospital and the medical school Staff Subscribers to a nonprofit 21 29,000 cooperative *At least 90 percent of the members of each plan reside in Dane County, except for Group B in which one-third reside outside Dane County. tThis number includes subcontracted primary care groups outside of Dane County.
Physician Adaptation to HMOs
47
active practice was by active hospital medical staff membership. This became evident after comparing licensing board, medical society and hospital staff lists. We included in the study all active staff members from four community hospitals and the university hospital. Physicians practicing at the Veterans Administration hospital and house staff in training programs were excluded. The University of Wisconsin Survey Research Laboratory (WSRL) conducted the physician surveys. Respondent names were coded by WSRL to ensure confidentiality. In October 1983 -after the major HMOs had been formed but before the change to HMOs on January 1, 1984-questionnaires were mailed to physicians to ask about their support for HMO development. The questionnaires specifically asked about the anticipated effect of HMOs on the respondent's own practice and on medical care in the community. In the summer and fall of 1986, a follow-up survey was mailed to 850 physicians in Dane County. This second survey contained questions regarding the impact of HMO development after about two and one-half years experience. Our survey response rates are relatively high when compared to similar studies of physicians, lawyers, and other professionals. The response rate for the 842 physicians in the 1983 sample was 58 percent with only two follow-up surveys. However, the 1983 data are reported only for those doctors who also responded to the 1986 survey. The overall response rate for the 1986 survey was 65 percent. We report findings for all respondents (N = 545) in this larger sample, except when we are making a direct comparison with the 1983 data. In the 1986 survey, response rates exceeded 70 percent for primary care (family practice, general internal medicine, general pediatrics, and general OB/GYN). The response rates were lower for non-primary care referral specialists, university clinicians, and hospital-based specialists: 67 percent, 60 percent, and 54 percent, respectively. Because of a lower response rate, more caution is needed in interpreting results from hospital-based physicians in particular. Although there were five follow-ups to nonresponders in the 1986 survey, there was no evidence of selection bias among slower responders. Physicians who responded only after the third request were not significandy different (p < .10) from prompt responders in age, gender, type of practice, or in responses to study questions. Also, we compared responses before and after HMO development on a subset of 288 physicians who responded to both the 1983 and 1986 surveys. These 288 physicians were not significantly different in age, gender, and type of practice from respondents to the 1986 survey (p < .10),
48
HSR: Health Services Research 25:1 (April 1990, Part I)
although proportionately fewer hospital-based and referral specialists responded to both surveys. Of the 545 usable 1986 responses, by self-report, 152 were in specialties of family practice, internal medicine, OB/GYN, or pediatrics providing basically primary care. Another 316 reported that they were in general surgery, psychiatry, internal medicine, OB/GYN, or one of the subspecialties, and that their practice was mainly referral based. The remaining 75 respondents were hospital based in anesthesiology, emergency medicine, -pathology, or radiology. About 14 percent of the responding physicians were female, and 57 percent were 46 years of age or younger. For most survey items, Likert-type scales were used to measure physician attitudes concerning HMO development and its impact. When asked to assess the effect of HMOs on quality of care and physician autonomy, the doctors themselves were required to interpret what the terms "quality" and "autonomy" actually mean. The survey data were buttressed by three-hour interviews with administrators and medical directors using the "Organizational Structure of HMOs" instrument from the National Center for Health Services Research (1984). This interview schedule included questions concerning how HMOs manage health care and darifying the specific nature of their contractual arrangements with hospitals and hospitalbased specialists. To further validate survey findings, informal interviews concerning the impact of HMOs were conducted with three or more physicians from each HMO and from the group of physicians not joining an HMO. t-Tests are used to test the difference in responses between HMO and FFS settings and between the 1983 and 1986 perceptions. An ordered probit analysis, most appropriate for ordinal-level dependent variables (Winship and Mare 1984), is used to help determine the factors that explain physician support for HMO development.
FINDINGS 1. What was expected and what was the resulting impact on physicians' practices from the change to HMOs? Table 2 reports findings for the subsample of physicians who responded to both the 1983 and 1986 surveys. It shows that for all measures of the impact of HMO development, the reported experience was more favorable than doctors had projected. These differences were most dramatic regarding the actual effect of HMOs on paperwork, earnings,
Q~ ~ zz z z E~~~~~~~eM CC m C1s C
LO
LO ° C oo 'to C q Lo c
co
COC Co co
en
z~
co
_ Co
Co~~~~~~~~V
w
4
Co
- e~~~~~~~ PLi 04
>
C) 0 En
CQ
Co
Lm
nO L
0o O
X
Lo
CoLo
O0
00
L
"0
U:^ U
t1
tM~~ ~ -
~~~~~
~~
LQ__ C, C1U:
_
ena~
Loen
°U
*~ C
N.'0
~
~ ~~
LOC4O -+
~
~
~
"0C1-44
°
O
~
oo4)_
t0-
0
o '-
a)
10-C
~~~~~~
_-
Coq
1
c
a
>' e k 5.5
UbiD
Co~~~~~~~~~~ c
CUv
~~Z4~4~
c
~CoO~~
~
e
a
c
t
U)v o.,C
Physician Adaptation to HMOs
55
satisfied with HMO patients and the percentage satisfied with FFS patients for virtually all categories except the ability to refer. The absence of any difference in satisfaction with HMO patients and satisfaction with FFS patients is found within each of the primary care specialties as well. Finally, for physicians who changed from FFS to more than 10 percent HMO patients, there was a significant difference in satisfaction with HMO and FFS patients only with respect to earnings and ability to refer patients to consultants. Assuming that hospital-based and referral specialists have higher take-home incomes than primary care physicians (Owens 1986), it is interesting that primary care physicians are more satisfied with their incomes than are hospital-based physicians. Indeed, the satisfaction of primary care physicians with HMO incomes is equal to the satisfaction of referral specialists with their income from FFS patients. We also investigated to see if the percentage of HMO patients in a physician's practice (or a physician's presence in an HMO) affected overall work satisfaction or satisfaction with incomes from practice. We found no significant correlation (Pearson's R) between any of these variables. Figure 2 presents the results of an ordered probit analysis of variables affecting the level of support for HMOs among physicians. Possible survey responses consist of five levels of support (very opposed, opposed, neutral, supportive, very supportive). When entered simultaneously in the probit analysis, several variables are significant (p = .01 or better) in predicting a higher level of support for HMOs. These variables are perceptions that HMOs have not reduced the respondent's autonomy as a physician, that HMOs are at least as cost effective as FFS, that the quality of medical care has not been reduced by HMOs, that the respondent has at least 10 percent HMO patients, and that the respondent is in an HMO. When broken down by HMO (see appendix), Group B and the university plan are the most significant predictors of support among HMOs. Additional significant predictors include not being dissatisfied with income received from HMO patients, and being a primary care physician rather than a hospitalbased or referral specialist. The age and sex of the respondent (included in the probit analysis in the appendix) are not significantly associated with level of support for HMOs.
56
HSR: Health Services Research 25:1 (April 1990, Part I)
Figure 2: Results of an Ordered Probit Analysis -Variables Helping to Predict Physician Support for HMO Development No Decline in Autonomy
HMO as Cost
Effective as FFS
No Decline in
Quality
10% or
Not
More HMO Patients
Dissatisfied
In an HMO
In with HMO Primary Income Care
.7
.6
.5
.4
.3
.2
.1
For the purpose of simplified presentation and direct comparison, all explanatory variables have been dichotomized by giving positive and neutral responses a score of 1 and negative responses a score of 0. The heights of the bars are proportional to the probit coefficients, all of which were significant at the .01 level (two-tailed test). Chi-square for this simplified model is 219.2, d.f. = 7, p = .001.
CONCLUSIONS AND IMPLICATIONS In summary, we found that most physicians expected the change to HMOs to result in less autonomy, lower earnings, more paperwork, and lower quality of care. Nevertheless, except for some loss of auton-
Physician Adaptation to HMOs
57
omy, only about one-third reported that such apprehensions materialized. Second, most physicians perceived a loss in autonomy with the development of HMOs. Even most physicians who did not join an HMO reported that their autonomy dedined, presumably because they were limited in traditional referral patterns or were forced into discounted charges. Interestingly, over 84 percent of physicians in Group A reported a decline in autonomy while only 44 percent in Group B reported a decline. Yet, based on interviews in both groups, it was apparent that control procedures over physicians' HMO patients were more rigorous in Group B than in Group A. Perhaps autonomy is more a feeling than a fact. Perceived autonomy may be a function of factors other than actual autonomy - for example, expectations, changes in the status quo, achievement of goals, feelings of control, and earnings that appear to be high when viewed in the context of actual constraints (i.e., the constraints in Dane County HMOs). Third, the majority of physicians reported that their earnings did not decline. This finding is surprising considering that managers of all HMOs said that gross income per patient was substantially less for HMO patients than for FFS patients. Perhaps in the short run at least, growth in patient volume and shifting of expenses to FFS patients and affiliated organizations (such as hospitals and the medical school) can absorb cost savings to HMO patients. However, if the number of HMO patients continues to increase and HMO premium competition continues, opportunities for making up income reductions from HMO patients will decline. Fourth, it is physicians who have had little or no experience with HMOs who are most likely to report that quality has declined. With few exceptions, empirical evidence suggests that quality of care in HMOs is comparable to that of FFS (Luft 1981; Hornbrook and Berki 1985; Cunningham and Williamson 1980). Our findings show that most physicians in Dane County who were treating HMO patients reported that quality of care did not decline with HMO development (although one might not expect a physician to deprecate his or her own service). In light of the overall evidence, it is quite possible that states ments about inferior HMO quality, made by physicians without firsthand experience, are based on fears, not observations. Fifth, except for some frustration regarding their lack of freedom to refer patients at will, primary care physicians appear to be as satisfied treating HMO patients as treating FFS patients. However, referral and hospital-based specialists are significantly less satisfied with HMO patients than with FFS patients. This may be attributable to percep-
58
HSR: Health Services Research 25:1 (April 1990, Part I)
tions of loss of autonomy due to transfer of some power to primary care physicians, who assume a gatekeeper role. Also, loss of autonomy may be attributed to the monitoring function and control assumed by HMO plan managers. Accompanying this loss of autonomy are reports by many subspecialists that referrals have declined. In addition, because HMOs have extracted substantial discounts from subspecialists and hospital-based physicians, these doctors are more likely to express dissatisfaction with HMO patients. It is also noteworthy that primary care physicians, who might experience some strains due to their gatekeeper role, reported no significant difference in satisfaction in their patient relationships with HMO patients versus FFS patients. This is possibly an important finding because of the reported problem of a "more demanding patient" in an HMO (Luft 1981). It should also be noted that in Dane County, Medicaid and general relief patients, who are required to enroll in an HMO, represent as many as 18 percent of the patients in one HMO. Findings from experiences in Dane County suggest that, as with any change in the status quo, unless there is strong demand for change among those who will be most affected by the change, there are fears about the consequences of the change (Dalton 1973). However, results from this survey suggest that most physicians who changed from FFS practices to serving a substantial number of HMO patients did not perceive that the actual change had serious adverse effects. This is a rather remarkable finding considering the magnitude of changes in Dane County in a short period of time. Although some physicians have been hurt by the change and are vocal in their complaints, we can document only eight physicians (fewer than 1 percent) who said that their departure from Dane County or their early retirement was at least in part because of HMO development. Is the Dane County experience atypical of what might be expected of physician responses to HMO development in other communities? For example, our findings are in conflict with a survey in Minnesota that found that most physicians, especially those in the Twin Cities, were unhappy with HMOs (Dombrosk 1988). (However, it should be noted that only 28 percent responded to the Minnesota survey, and that the responses could have been biased toward those who were most disgruntled.) If it is atypical, one difference may be that in Dane County the doctors themselves organized the new HMOs. (Although in some cases the formation of these HMOs initially occurred in partnership with a hospital or insurance carrier, some of these were later excluded from ownership.) Whether or not physicians are treated any better in an HMO they own, they may feel better about an HMO that
Physician Adaptation to HMOs
59
they have helped to develop. A second difference is that physicians in Dane County have been accustomed to practicing in an organized setting. The vast majority of physicians have been in a group practice or medical school. On the other hand, the results show (see appendix) that physicians who were in solo or small group practice and are now in the closed-panel IPA also tend to be supportive of HMO development. Other contributing factors to the successful transformation may be that physicians were conditioned to competition through various clinics, hospitals, and medical school organizations in a community with no physician shortage. Moreover, physicians had previous experience with an HMO through their open-panel medical society IPA. Nevertheless, many of the pre-HMO conditions in Dane County existed in the Twin Cities as well. Furthermore, high HMO penetration has existed longer in the Twin Cities than in Dane County. Perhaps there is a certain life cycle of satisfaction with HMO development. It is also apparent that, as might be expected, HMO development contributes to a shift in influence favoring primary care physicians. In an HMO, primary care physicians have "gatekeeper" controls that are not present in a FFS system. Furthermore, there is evidence of income leveling in some HMOs to the disadvantage of referral and hospitalbased specialists. The change to competitive HMO systems has been a major disruption. The change has resulted in the virtual elimination of independent solo or small group practices. Most of these physicians have had to join or form large multispecialty groups or watch their patient base erode. Consequently, the repercussions of the change from FFS to HMOs may be greater than the change itself. Nevertheless, even with such repercussions, less autonomy, and lower earnings, there is to date little evidence of general disaffection with medical practice in Dane County. We propose that physicians' perceptions about the impact of a change from FFS to HMOs-even after the change occurs-may reflect more how it was accomplished, physicians' roles in effecting it, and physicians' expectations of results than the actual change itself. In the Dane County experience, fears before the change may have cushioned perceptions of actual results. Moreover, in this case, physicians developed their own HMOs to help control their own destinies. For the most part, these HMOs have been successful in retaining the number and types of patients (if not the autonomy and income) to which Dane County physicians are accustomed. What are the implications of these findings for persons seeking physician support for HMO development? We suggest the following:
60
HSR: Health Services Research 25:1 (April 1990, Part I)
1. In recruiting physicians for the HMO, expectations should not be raised beyond what is achievable. Results that are better than expectations facilitate satisfaction (Lawler 1973). According to HMO officials, one of the reasons why physicians in Group A perceived that earnings declined (see Figure 1) was that overexpectations had been created by unrealistically high earnings in the first year. 2. Physicians should be committed to the success of the HMO. Although financial incentives are important in this regard, participation in management can also increase a sense of ownership and organizational commitment. Participation has been found to be a significant predictor of physician satisfaction (Schulz and Schulz 1988; Barr and Steinberg 1983; Nathanson and Becker 1973). 3. Believing that the HMO is cost effective-it is achieving what it is supposed to achieve-appears to be an important predictor of physician support for HMOs. In the case of Dane County, the state believes that HMOs have saved millions of tax dollars (Owens 1986). Subscribers, too, are generally pleased (Scheckler and Schulz 1987), and most Dane County physicians believe that HMOs are cost effective and that quality of care is as high or higher than it was before. HMO leadership needs to ensure that it is, and to make evidence of this available. 4. Although perceptions of autonomy are an important predictor of support, there is preliminary evidence to suggest that perceived autonomy may be a function of participation in management affairs in addition to actual clinical autonomy (Schulz and Schulz 1988). Participation in management information and decisions facilitates a feeling of control over environmental forces. 5. A large number of HMO patients, which is an indicator of the success of the HMO, was also found in our study to be an important predictor of support for HMOs. Physicians repeatedly stated in interviews that the primary motivation for organizing or joining an HMO was to retain patients. Indeed, physicians who did not join an HMO stood to lose over one-third of their patients (Scheckler and Schulz 1987). Presumably, physicians with fewer HMO patients either lost patients or had increasing anxieties about losing them.
Physician Adaptation to HMOs
61
6. It appears that primary care physicians -shown in our study to be the most supportive of HMO development -may provide a bridge for HMO managers seeking to build support among other physicians. 7. Satisfaction with quality of care and income from HMO patients are other factors that account for HMO success and physician support for HMOs. HMO managers should seek to dispel anxiety that quality of care and amount of income will necessarily dedine.
The leadership of HMOs obviously should strive to maintain and improve quality of care, cost effectiveness, earnings, and the autonomy of physicians to practice what they were trained to do. However, success is measured relative to expectations and to perceptions of efforts to achieve expectations. Physicians who share in setting goal expectations, in information on how well the organization is doing, and in decisions to achieve goal expectations are likely to be more satisfied than those who do not (Schulz and Schulz 1988; Barr and Steinberg 1983). Further, physicians thus participating are more likely to perceive that organizational effort is being made to achieve high-quality care (Schulz, Girard, and Harrison 1989). This is still an early chapter in the transformation of health services to HMOs in Dane County. More study is needed on the longerrange effects of this change. However, initial evidence from Dane County suggests that, although physicians may be apprehensive about the change to competitive, closed-panel HMOs, it is possible for these physicians to become generally supportive and satisfied once the change is implemented.
APPENDIX Ordered Probit: Variables Helping to Predict Physician Support for HMO Development (N= 387) Referral specialists Hospital based Percent of patients in HMO HMO model: IPA Group A
Coefficient -.30* -.42t .20** .39t .48t
t
-2.2 -1.7 2.9 1.9 1.9 Continued
62
HSR: Health Services Research 25:1 (April 1990, Part I)
Appendix: Continued Coefficient .65** .66 .51** .53***
t 3.0 1.3 2.6 3.6
Lower quality of care in HMOs
-.49***
-3.9
Level of dissatisfaction with income from HMO patients
1.14***
-3.8
HMOs are less cost effective
-.41***
-4.6
Control variables: Age of physician Sex of physician (male - 1)
-.00 .06
-0.3 0.4
Group B Staff University Reports of no decline in autonomy
Ordered probit threshholds: -6.1 -3.5*** Very supportive/Supportive -4.2 -2.3*** Supportive/Neutral -2.1 -1.2* Neutral/Opposed 0.4 0.2 Opposed/Very opposed -2 x (log likelihood) - 910.4 Chi-Square -256.1 (d.f. = 14, p 10%, 2 10-25 %, 3 = 26-50%, 4 51-75%, 5-76-100%; Quality-i -increase, 2-same, 3-decrease; HMO income-I - very satisfied, 2 = satisfied, 3 - somewhat satisfied, 4 neutral, 5 somewhat dissatisfied, 6 - dissatisfied, 7 very dissatisfied; cost effectiveness of HMOs relative to pre-HMO system -1 more, 2 - same, 3 - less; age -actual age. =
=
=
*p
