PHYSICIAN INCENTIVES: Hurt MD Job Satisfaction

      Physicians working under a managed care contract with financial incentives tied to referrals and productivity are less happy with their jobs and believe patient care is compromised, but incentives based on quality of care and patient satisfaction can actually increase physicians' job satisfaction and improve care, according to a new study. A "special article" published in today's New England Journal of Medicine based on a 1996 survey of 766 primary care doctors in California with at least one managed care contract, found that "[n]early 40% of all the respondents reported that their contracts ... included some form of incentive," which comprised a median of 7% of their overall income -- representing about $10,500 annually. Of all doctors surveyed, 57% felt pressure to limit referrals, with 17% believing that "such pressure compromised patient care"; 75% "felt pressure to see more patients per day," with 24% feeling this compromised patient care. Incentives tied to patient satisfaction and quality of care did not significantly increase pressure on physicians. When the incentives were analyzed in relation to physician job satisfaction data, the researchers found that on average, doctors with incentives to limit referrals and maximize patient visits were more dissatisfied with their jobs, while doctors with quality and customer satisfaction incentives were happier with their jobs. Additionally, the study found that physicians in "traditional, nonprofit HMOs" were less likely to eel pressure to limit referrals, but were more likely to feel pressure to see more patients each day.

Unlikely To Help
      The researchers, led by Dr. Kevin Grumbach of the University of California-San Francisco, concluded, "Incentives that depend on limiting referrals or on greater productivity apply selective pressure to physicians in ways that are believed to compromise care." They add, "High-quality care is unlikely to flourish in an environment that leaves physicians demoralized and leads many to believe that the standards of care have been compromised." The study advocates incentives that encourage quality of care and patient satisfaction, rather than "reward[ing] physicians for restricting access to specialty care or for squeezing in a greater number of visits per day" (Grumbach et al., NEJM, 11/19 issue).

If You're Unhappy and You Know It
      An accompanying NEJM editorial by NEJM Editor-in-Chief Dr. Jerome Kassirer on "Doctor Discontent" charges that the managed care revolution has made "[m]any American doctors ... unhappy with the quality of their professional lives." Kassirer argues that as physicians increasingly resent constraints on their time and intrusions into their professional decision- making, and as a result are selling their private practices, opting out of managed care by accepting only indemnity insurance and out-of-pocket payments or attempting to unionize, while "[s]ome have simply given up." The editorial charges that "[t]hese trends should concern us for many reasons," including an erosion of the doctor-patient relationship and exposing doctors to financial risks. Kassirer concludes, "One thing we know: disgruntled, cranky doctors are not likely to provide outstanding medical care. Payers, insurers and legislators must recognize this predicament and stop pretending that doctor discontent doesn't matter" (Kassirer, NEJM, 11/19 issue).

Can't Get No Satisfaction
      Although it comes as no surprise to anyone who has followed persistent physician disputes with HMOs, the Grumbach study "broke ground in examining the link of financial incentives to such unhappiness," Kassirer said. Patrick Hayes, president and CEO of the Blue Cross and Blue Shield Association, said, "Managed care is a work in progress. There's no question about our needing to reinvent managed care as it has been implemented in the last 10 or 15 years" (Kilborn, New York Times, 11/19). However, American Association of Health Plans spokesperson Susan Pisano noted that 82% of the physicians surveyed are satisfied with their jobs, and disputed the laying of blame on the managed care industry for instituting various incentives. She said "incentive programs are often determined not at the health plan level, but by the doctors" themselves. She predicted that quality and satisfaction measures would be incorporated with productivity incentives in the future (Greenberg, AP/Boston Globe, 11/19).