Physician Satisfaction with Medicaid Managed Care

,

Original Research

Physician Satisfaction with Medicaid Managed Care

J Fam Pract. 2000 January;49(1):20-26

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Sample Selection

We sampled 2 groups of primary care physicians. The Medicaid managed care sample was made up of physicians in eastern and central Missouri participating in Medicaid managed care. Physicians in northern and southern Missouri participating in traditional Medicaid made up the traditional Medicaid sample. We defined primary care physicians as family physicians, general practitioners, primary care pediatricians, primary care internists, and obstetrician-gynecologists. The Missouri Division of Medical Services provided 2 databases of primary care physicians participating in Medicaid managed care or traditional Medicaid. A random sample of 670 physicians was drawn from each database. The sample size was determined by assuming an 80% power to detect a 10% difference of proportions between groups, with a 2-sided P value of .05 and a projected response rate of 50%. Subsequently, each sample was matched with the state licensure database. Physicians were not eligible to participate in the survey if they were identified as specialists either by the state licensure database or by self-report.

Survey Administration

We mailed the questionnaire 3 times in the fall and winter of 1996-1997. Each mailing was sent with a cover letter signed by the principal investigator and the head of the Missouri Division of Medical Services. Postcard reminders were mailed after the first and third mailings. Methods to increase the response rate included hand-written thank you notes, hand-signed signatures on the cover letter, and the inclusion of a token gift.^34,35 One mailing was sent by Priority Mail.

Statistical Analysis

We performed a principal component analysis followed by an orthogonal rotation on the 15 items comprising the satisfaction portion of the survey instrument. That was followed by a Cronbach’s a internal reliability analysis on the resulting factors.

We used chi-square tests to compare respondents with nonrespondents. Comparisons within the Medicaid managed care sample were performed using the Wilcoxon signed-rank test, and comparisons between samples were done with the Wilcoxon rank sum test. Because of multiple comparisons, we set statistical significance at P = .01. We measured bivariate relationships between possible predictor variables and overall satisfaction with Medicaid managed care using Spearman rank correlation test coefficients. We performed multivariable analysis using forward stepwise multiple linear regression. In regression analyses, dependent variables met the .05 significance level for inclusion in the models. We deleted cases with missing data from our analysis.

We performed statistical tests with SAS software (version 6.1, SAS institute, Cary, NC) or SPSS software (version 7.5.2, SPSS, Chicago, Ill).

Results

Response Rate

We excluded the following from the study: 265 specialists; 48 physicians who were not participating in Medicaid programs, not in practice, or still in training; and 57 physicians whose surveys were not deliverable. There were 505 usable responses received from the remaining 970 eligible physicians, for a response rate of 52%. The response rates in the traditional Medicaid and Medicaid managed care samples were 57% and 46%, respectively. The characteristics of the respondents are shown in Table 1. When comparing respondents with nonrespondents in the Medicaid managed care sample, pediatricians and family physicians were more likely to respond than internists and obstetricians (P <.001), and rural physicians were more likely to respond than urban physicians (P = .022). In the traditional Medicaid sample, family physicians and pediatricians were also more likely to respond than were internists or obstetricians (P = .002), and allopathic physicians were more likely to respond than were osteopathic physicians (P = .036). There were no significant differences in measures of satisfaction between responses received after the third mailing and responses received before the third mailing (P = 0.15 by Kruskall-Wallis test for both comparisons).

Questionnaire Analysis

Factor analysis confirmed 3 measures of components of physician satisfaction: clinical autonomy, organizational autonomy, and patient relationships. The clinical autonomy scale was made up of 6 items. These items measured satisfaction with the physician’s ability to hospitalize patients, prescribe medicine, choose specialists, order tests, obtain prior authorization, and control number of patient visits. Four items comprised the organizational autonomy scale, which measured satisfaction with communications with insurers about billing and payment, enrollment, prior authorization, and utilization review. Three items comprised the patient relationship scale: satisfaction with continuity, the quality of patient relationships, and the intellectual challenge posed by patient problems. The internal consistency of these 3 scales measured by Cronbach’s a ranged from 0.76 to 0.90. Two reimbursement items were grouped together on factor analysis and were treated as a scale.

Overall Satisfaction by Insurance Type

Figure 1 The Figure shows that physicians were more likely to respond that they were satisfied or very satisfied with commercial managed care (40%) and their previous experience with traditional Medicaid (39.7%) than with Medicaid managed care (28.6%). There was no difference in satisfaction between Medicaid managed care and satisfaction with traditional Medicaid measured in the traditional Medicaid sample (29.8%).