Physician Satisfaction with Medicaid Managed Care

,

Original Research

Physician Satisfaction with Medicaid Managed Care

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

By

John D. Gazewood, MD, MSPH

The Missouri Experience

References

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BACKGROUND: Medicaid managed care is important to health reform at the state level. However, little is known about physician satisfaction with these programs. We sought to measure this satisfaction in Missouri and determine its predictors.

METHODS: We surveyed a random sample of primary care physicians participating in Medicaid managed care (n = 670) or traditional Medicaid (n = 670). Primary outcomes measured were physicians’ satisfaction with Medicaid managed care, traditional Medicaid, and commercial managed care. Satisfaction was measured on a 5-point Likert-type scale.

RESULTS: The response rate was 52%. Physicians participating in Medicaid managed care were less likely to be satisfied or very satisfied with Medicaid managed care (28.6%) than with commercial managed care (40%) or their previous experience with traditional Medicaid (39.7%). Among physicians participating in traditional Medicaid, 29.8% were satisfied or very satisfied with traditional Medicaid. Physicians participating in Medicaid managed care were less satisfied with clinical autonomy under that system in comparison with their previous experience with traditional Medicaid (relative difference = 10.8%, P =.001). In multiple linear regression analyses, clinical autonomy (R2 = 0.40) was a strong predictor of overall satisfaction with Medicaid managed care.

CONCLUSIONS: Enhancing physicians’ clinical autonomy may result in improved satisfaction with Medicaid managed care. State Medicaid agencies should include physician satisfaction as a measure of Medicaid managed care plans’ quality.

Although national attempts at comprehensive health care reform have faltered, many state governments have developed and implemented reform initiatives. In particular, rising Medicaid expenditures and concerns about inadequate access to care have led 49 states and the District of Columbia to experiment with Medicaid managed care.¹ The proportion of the United States Medicaid population enrolled in managed care plans increased from 10% in 1991 to 48% in 1997.¹ In Missouri, rising Medicaid expenditures led to the state government’s decision to enroll Aid to Families and Dependent Children (AFDC) program recipients in the state’s eastern, central, and western regions in Medicaid managed care beginning in 1995.^2,3 Traditional Medicaid continued to cover the AFDC populations in Missouri’s southern and northern regions.²

There are ongoing concerns about the quality of care provided to patients in Medicaid managed care plans.^4-8 Low rates of physician participation have plagued traditional Medicaid programs and have adversely affected access and quality of care.⁹ Increasing primary care provider participation in Medicaid managed care programs is critical for improving the quality of care provided to Medicaid recipients.⁹ Thus, efforts to increase physician participation may be necessary to improve the quality in those programs.

Physician satisfaction has been associated with outcomes important to patients, insurers, and state governments. In one study, physician satisfaction was correlated with patient satisfaction, increased continuity of care, lower patient no-show rates, and more reasonable charges for follow-up visits.¹⁰ Less satisfied general practitioners in England were more likely to prescribe inappropriate drugs.¹¹ Physician satisfaction was also found to predict physician turnover¹² and was associated with participation in the Ontario physician strike.¹³ Therefore, physician satisfaction with Medicaid managed care may affect both quality of care and physician participation in the program.

A number of studies have examined physician satisfaction in traditional fee-for-service, managed care, and institutional settings. Clinical autonomy is strongly predictive of physician satisfaction.^12,14-16 Organizational autonomy (the ability of a physician to control his or her workplace),^14-16 satisfaction with income,^13,15,17 and satisfaction with patient relationships^10,12,13 have also been found to predict physician satisfaction.

From a theoretical perspective, autonomy is central to the role functioning of physicians in the physician-patient relationship.¹⁸ This relationship has therapeutic qualities beyond those of any prescribed or recommended intervention.^19-21 Health care system changes that affect physician autonomy may have an impact on the nature of the physician-patient relationship, as well as affect physician satisfaction.^22-24

The purposes of our study were to assess level of physician satisfaction with Medicaid managed care in comparison with traditional Medicaid and commercial managed care and to identify the determinants of physician satisfaction with Medicaid managed care.

Methods

Design

We performed a cross-sectional survey of primary care physicians participating in Medicaid managed care or in traditional Medicaid after the implementation of Medicaid managed care in eastern and central Missouri.

Questionnaire Development

We used a literature review to identify topics for the questionnaire.^{12,15-17,25-33} The questionnaire included items about physicians’ satisfaction with: their ability to care for patients; their communications with third-party payers; and their satisfaction with patient relationships and reimbursement. Physicians participating in Medicaid managed care were asked to answer these questions according to their current experience with Medicaid managed care and commercial managed care and their previous experiences with traditional Medicaid. Physicians participating in traditional Medicaid were asked to answer these questions according to their current experience. A single item was used to measure overall satisfaction with type of insurance. We measured global physician satisfaction with the practice of medicine using a previously validated scale.¹⁷ All responses were measured on a 5-point scale, where 1 = very dissatisfied and 5 = very satisfied. Other items measured the level of physicians’ input into their practices’ decision-making process, the number of Medicaid managed care plans in which they participated, and demographic information. The questionnaire was pilot-tested on groups of academic and community family physicians in Missouri. After it was revised, physician members of the Missouri Division of Medical Services quality improvement project reviewed it. The final instrument included 40 questions and took apporoximately 15 minutes to complete.*