Bindman A B, Grumbach K, Vranizan K, Jaffe D, Osmond D
Primary Care Research Center, Division of General Internal Medicine, San Francisco General Hospital, University of California, 94110, USA.
JAMA. 1998 Mar 4;279(9):675-9. doi: 10.1001/jama.279.9.675.
Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory.
To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care.
Cross-sectional mail survey of a probability sample of primary care physicians.
A total of 13 large urban counties in California.
Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice.
Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts.
Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice.
Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.
对于医生在加入管理式医疗网络时可能遇到的问题，以及管理式医疗计划选择医生的过程是否具有歧视性，人们了解甚少。
调查医生的管理式医疗合同被拒绝或终止的发生率及预测因素，以及这些拒绝和终止对初级保健医生参与管理式医疗的影响。
对初级保健医生概率样本进行横断面邮件调查。
加利福尼亚州的13个大型城市县。
在门诊执业的初级保健医生（家庭医学、内科、妇产科或儿科）。
与独立执业协会（IPA）或健康维护组织（HMO）的合同被拒绝或终止情况以及管理式医疗合同情况。
在947名受访者（回复率71%）中，520人从事门诊初级保健工作。在对抽样和回复率进行调整后，22%的初级保健医生的IPA或HMO合同被拒绝或终止，但87%的门诊初级保健医生至少有1份IPA或直接的HMO合同。个体执业是经历合同被拒绝或终止以及既没有IPA合同也没有直接HMO合同的最强预测因素。医生的年龄、性别和种族并不能预测其参与管理式医疗的程度。然而，医生的患者人口统计学特征与参与管理式医疗有关；参与管理式医疗的医生的患者中未参保和非白人患者的比例显著较低。经历合同被拒绝或终止的医生的按人头计费患者较少。
合同被拒绝和终止虽然相对常见，但并不妨碍大多数初级保健医生参与管理式医疗。管理式医疗的选择性签约似乎并非基于医生特征进行系统性歧视，但可能对为服务不足人群提供更多医疗服务的医生存在偏见。
