Burns L R, Alexander J A, Shortell S M, Zuckerman H S, Budetti P P, Gillies R R, Waters T M
Health Care Systems Department, Wharton School of the University of Pennsylvania, Philadelphia 19104, USA.
Med Care. 2001 Jul;39(7 Suppl 1):I9-29. doi: 10.1097/00005650-200107001-00002.
Health care systems have developed many types of contracting vehicles with physicians. The immediate aim of these vehicles has been to foster physician commitment and alignment to the system. The ultimate aim of these vehicles has been to garner managed care contracts, reduce costs, and improve quality. To date, most of these vehicles have failed to improve physician commitment. This may be one reason why the ultimate outcomes have not been observed. Consequently, systems are experimenting with new methods to partner with physicians. One new method is to segment physicians into tightly linked and loosely linked strategic alliances and devote different levels of resources and attention to each.
This study evaluates whether the segmentation of physicians into tightly linked versus loosely linked strategic alliances improves the commitment of physicians to the system. The study then investigates which constituent elements of the tightly linked strategic alliances exhibit the greatest association with commitment. DESIGNS AND SUBJECTS: The study uses a cross-sectional design and survey data drawn from 1,965 physicians affiliated with 14 health care systems around the country. Tightly linked physicians typically practiced in hospital-sponsored group practices, whereas loosely linked physicians typically used the system's hospitals as their primary site of inpatient practice.
Commitment is measured by seven different scales drawn from the literature on organizational commitment, loyalty, and identification. Some of the scales refer to physician attitudes, whereas others describe physician behaviors. The literature suggests that commitment is associated with both instrumental/utilitarian considerations (eg, older age, tenure with system, admissions to system, receipt of a stipend, etc.) as well as administrative involvement/participation considerations (eg, decision-making roles). A series of physician background and practice characteristics are used here to model these two types of factors.
The study finds small but significant differences in commitment between physicians in tightly linked versus loosely linked alliances. Multivariate analyses suggest that instrumental/utilitarian factors (eg, age, receipt of stipend, percent of admissions to the system) may exhibit stronger associations with commitment than the physician's administrative involvement in the organization.
To the degree that physician commitment is possible, systems should appeal to physicians' calculative motivations using extrinsic rewards rather than normative involvement in the organization.
医疗保健系统已与医生发展出多种签约模式。这些模式的直接目标是促进医生对该系统的投入与契合。其最终目标是获得管理式医疗合同、降低成本并提高质量。迄今为止，这些模式大多未能提高医生的投入度。这可能是未观察到最终成效的原因之一。因此，各系统正在试验与医生合作的新方法。一种新方法是将医生分为紧密型和松散型战略联盟，并对每个联盟投入不同程度的资源和关注。
本研究评估将医生分为紧密型与松散型战略联盟是否能提高医生对该系统的投入度。然后研究紧密型战略联盟的哪些构成要素与投入度的关联最为显著。
本研究采用横断面设计，并使用从全国14个医疗保健系统的1965名医生收集的调查数据。紧密型联系的医生通常在医院主办的团体诊所执业，而松散型联系的医生通常将该系统的医院作为其住院治疗的主要场所。
投入度通过从关于组织承诺、忠诚度和认同的文献中选取的七种不同量表进行测量。其中一些量表涉及医生的态度，而其他量表则描述医生的行为。文献表明，投入度既与工具性/功利性因素（如年龄较大、在系统内的任期、加入系统、获得津贴等）有关，也与行政参与/参与度因素（如决策角色）有关。这里使用一系列医生背景和执业特征来对这两类因素进行建模。
研究发现紧密型与松散型联盟中的医生在投入度上存在虽小但显著的差异。多变量分析表明，工具性/功利性因素（如年龄、获得津贴、在该系统的入院百分比）与投入度的关联可能比医生在组织中的行政参与度更强。
在可能提高医生投入度的程度上，各系统应利用外部奖励来吸引医生的算计动机，而非规范其在组织中的参与度。
