Center for Clinical Innovation, Parkland Health and Hospital System, 8435 N. Stemmons Freeway, Suite 1150, Dallas, TX, 75247, USA; Department of Pediatrics, Columbia University College of Physicians and Surgeons, 630 West 168th Street, New York, NY, 10032, USA.
Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 South Huntington Avenue (152M), Boston, MA, 02130, USA; Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
Soc Sci Med. 2019 Jul;233:208-217. doi: 10.1016/j.socscimed.2019.04.045. Epub 2019 May 2.
Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings. We investigated whether physicians' perceptions of autonomy support and job control significantly moderate the relationship between practice satisfaction and guideline adherence in a pay-for-performance context. We performed secondary analysis of a study dataset created by merging prospective information on clinical services provided by Rochester (NY)-based primary physicians (N = 156) during the years 2001-2004 with census data on specific characteristics of their ambulatory-care populations, claims-sourced information on attributes of their primary care practices, and survey data on their work-related attitudes. Greater job satisfaction had a significant multivariate association with lower adherence (β = -0.139; p=<.0001) among physicians that perceived low autonomy support from the market-dominant payer organization. For physicians experiencing high autonomy support, a positive satisfaction-adherence association existed (β = 0.105; p=<.0001). Low job control was a negative moderator (β = -0.103; p=<.0001), and high control a positive moderator (β = 0.071; p=<.0001), of the influence of job satisfaction on guideline adherence. Given the limitations of this study, such as the cross-sectional survey data and potential for unmeasured confounding variables, the validity of our findings should be tested by future research. We conclude that payers attempting to over-direct partner physicians can demotivate the satisfied physicians from achieving top-level guideline adherence, thereby squandering opportunities for intrinsic satisfaction to improve guideline adherence. To optimize the potential for job satisfaction to motivate greater guideline adherence, it may be important for payers to be perceptibly more supportive of physicians' autonomy and sense of job control.
基于价值的医师服务采购旨在激励更大程度地遵守临床实践指南。通过增加工作需求，新的报销模式可能会对工作满意度产生不利影响，并间接影响临床绩效。对医疗保健从业者满意度与绩效之间关系的研究得出了不一致的结果。我们研究了在绩效付费环境中，医师对自主性支持和工作控制的感知是否会显著调节实践满意度与指南遵从性之间的关系。我们对罗切斯特（纽约州）基础医生（2001-2004 年）提供的临床服务的前瞻性信息与他们的初级保健实践的特定特征的普查数据、源自索赔的信息以及他们的工作相关态度的调查数据进行了二级分析，从而创建了研究数据集。在感知到来自市场主导支付方组织的自主性支持较低的医师中，更大的工作满意度与较低的遵从性呈显著多变量相关（β= -0.139；p<.0001）。对于体验到高自主性支持的医师，存在积极的满意度-遵从性关联（β=0.105；p<.0001）。低工作控制是负向调节因素（β= -0.103；p<.0001），高控制是正向调节因素（β=0.071；p<.0001），可调节工作满意度对指南遵从性的影响。考虑到本研究的局限性，例如横断面调查数据和潜在的未测量混杂变量，未来的研究应检验我们研究结果的有效性。我们得出的结论是，试图过度指导合作医师的支付方可能会使满意的医师失去实现最高水平指南遵从性的动力，从而浪费了通过内在满意度提高指南遵从性的机会。为了使工作满意度更有可能激发更大的指南遵从性，对于支付方来说，重要的是要明显地更支持医生的自主性和工作控制感。
