Burdi M D, Baker L C
Stanford University School of Medicine, CA 94305-5092, USA.
Am J Manag Care. 1997 Sep;3(9):1357-66.
Managed care is widely expected to affect physicians throughout the healthcare system. In this study, we examined the relationship between health maintenance organization (HMO) activity and the level of competition, autonomy, and satisfaction perceived by physicians who do not work for HMOs. We obtained data on physicians from the 1991 Survey of Young Physicians, which contains a nationally representative sample of physicians younger than age 45 who had 2 to 9 years of practice experience in 1991. We examined the relationships between HMO market share and perceived competition, autonomy, and satisfaction using multivariate logistic regression. The main outcome measures were perceived level of competition; several measures of physicians' freedom to undertake common tasks that might be threatened by managed care (e.g., hospitalizing patients, ordering tests and procedures); satisfaction with current practice situation; perceived ability to practice quality medicine; whether the physician would attend medical school again; and satisfaction with medicine as a career. We found that an increase of 10 percentage points in HMO market share was associated with a 28% increase in the probability that physicians will regard their practice situation as very competitive as opposed to somewhat or not competitive (P < 0.01). Examinations of the relationship between HMO market share and autonomy and satisfaction revealed few significant results. We found no evidence that increases in HMO activity adversely affect physician autonomy. Only a limited amount of evidence indicates that increases in HMO activity reduce the satisfaction of specialist physicians, and no evidence associates HMO activity with the satisfaction of generalists. Although physicians perceive HMOs as competitors, HMO activity has not had a strong negative effect on the autonomy and satisfaction of physicians.
人们普遍预期管理式医疗会对整个医疗体系中的医生产生影响。在本研究中，我们考察了健康维护组织（HMO）的活动与那些不为HMO工作的医生所感知到的竞争程度、自主性和满意度之间的关系。我们从1991年青年医生调查中获取了医生的数据，该调查包含了1991年年龄小于45岁、有2至9年执业经验的全国代表性医生样本。我们使用多元逻辑回归分析了HMO市场份额与感知到的竞争、自主性和满意度之间的关系。主要结局指标包括感知到的竞争程度；医生在进行可能受到管理式医疗威胁的常见任务（如收治患者、开具检查和治疗项目）时的几种自主性衡量指标；对当前执业状况的满意度；感知到的实施高质量医疗的能力；医生是否会再次报考医学院；以及对医学作为一种职业的满意度。我们发现，HMO市场份额每增加10个百分点，医生将其执业状况视为竞争非常激烈而非有些竞争或无竞争的概率就会增加28%（P < 0.01）。对HMO市场份额与自主性和满意度之间关系的考察显示，几乎没有显著结果。我们没有发现证据表明HMO活动的增加会对医生的自主性产生不利影响。只有有限的证据表明HMO活动的增加会降低专科医生的满意度，没有证据表明HMO活动与全科医生的满意度有关。尽管医生将HMO视为竞争对手，但HMO活动对医生的自主性和满意度并没有强烈的负面影响。
