Effect of managed care and financing on practice constraints and career satisfaction in primary care.

BACKGROUND: The shift away from third party insurers to risk-sharing arrangements affecting care management and clinicians could be the most fundamental change in the health care system. Analysis was undertaken to study how managed care, practice setting, and financial arrangements affect physicians' perceived impact on their practice.
METHODS: Data were taken from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Survey instruments were completed by 7,146 primary care physicians in internal medicine (2,355), family practice (3,168), and pediatrics (1,623). The dependent variables are career satisfaction and perceived limitations and pressures on time spent with patients, clinical freedom, income, and continuity. To study the unique effect of financing and gatekeeping arrangements and practice setting, the dependent variables were regressed on gatekeeping, practice revenue, individual physician compensation, practice setting, specialty, age-group, sex, international medical graduate, board certification, and recent change in practice ownership.
RESULTS: Total managed care revenue, or individual physician incentives, have no effect on career satisfaction and relatively limited effects on time pressure, income pressure, or patient continuity. In contrast, primary care gatekeeping has a highly significant adverse effect on the same outcome measures. After controlling for financial factors, demographic characteristics, and training differences, physicians in solo and 2-physician practices are significantly more likely to be dissatisfied with their medical career, more likely to report no clinical freedom, and more likely to feel income pressure than physicians in group practices, staff model HMOs, medical schools, or other settings.
CONCLUSION: Physicians in solo and 2-physician practices were least satisfied with their careers and reported more constraints on their clinical freedom and income than physicians in other settings. Physicians in group practices or staff model HMOs are more likely to report time pressure than physicians in solo or 2-physician practices. Family practice falls between internal medicine (less satisfied, more practice constraints) and pediatrics (more satisfied, fewer practice constraints).