Escarce J J, Polsky D, Wozniak G D, Pauly M V, Kletke P R
RAND Health Program, Santa Monica, CA 90401, USA.
Med Care. 1998 Nov;36(11):1555-66. doi: 10.1097/00005650-199811000-00005.
The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME).
Conditional logit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician.
Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists.
New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.
健康维护组织的迅速发展正在重塑医生可获得的执业机会。新医生的执业地点选择是这些变化的一个敏感风向标。本研究评估了健康维护组织渗透对完成毕业后医学教育（GME）的医生执业地点的影响。
使用条件逻辑回归分析来确定健康维护组织渗透对执业地点的影响，并控制其他市场特征。研究对象是1989年至1994年间完成GME且位于美国98个人口超过50万的大都市区之一的医生。结果指标是每位新医生选择的特定大都市区。
在研究初期，新的全科医生比低渗透地区更有可能在健康维护组织渗透高的大都市区执业，而新专科医生的执业地点选择与健康维护组织渗透无关。然而，随着时间的推移，相对于低渗透地区，选择高渗透地区的可能性对于全科医生和专科医生都有所下降。因此，到研究期结束时，健康维护组织渗透对全科医生的执业地点有微弱但显著的负面影响，对专科医生的执业地点有强烈的负面影响。
1989年至1994年间完成毕业后医学教育的新全科医生比新专科医生更有可能在健康维护组织渗透高的市场地区执业；然而，在研究期间，选择高渗透地区的全科医生和专科医生的比例都有所下降。这一发现可能反映出随着健康维护组织控制利用的系统开始产生效果，高渗透地区相对于低渗透地区的执业机会减少。或者，新医生可能在接受高渗透地区的现有职位时变得更加犹豫。
