Data Collection
The ASPN central office recruited and trained participating practice personnel and coordinated project implementation. Between April and August 1997, practices were sent explicit protocol instructions and copies of the Managed Care Survey and the patient survey and were instructed to choose a start date for administering surveys to 50 consecutive patients of each participating clinician. Patients were asked to complete the survey before leaving the office. A preassigned number corresponding to the patient’s insurance plan was written on the survey before it was given to the patient. The staff also kept track of the age, sex, and insurance plan of those patients who declined to participate, so that any nonparticipation bias could be evaluated.
In addition, for each practice a single Managed Care Survey was completed jointly by a physician and office manager to characterize each individual managed care health care plan with a minimum of 5% of all patients. Each insurance plan on the survey was identified by the same number that was used on the corresponding individual patients’ health care plans on the patient survey.
Measures
Managed care was conceptualized as a set of organizational restraints and financial incentives that are intended to focus and limit clinicians’ use of health care resources. The Managed Care Survey was designed to characterize managed care plans along several dimensions. The survey was developed by the ASPN Task Force on Managed Care, which consisted of 6 family physicians from the United States and 1 from Canada representing diversity in gender, geographic location, organization of practice, managed care market, and years in practice. Group consensus was used to identify and define the key managed care features that represent organizational restraints, financial incentives, and other aspects affecting the restrictiveness of plans.
The plan features measured by the managed care survey included the proportion of each practice’s patients in the plan, the plan’s financial restrictiveness and organizational restrictiveness, and the level of hassle associated with it. The financial restrictiveness portion of the survey included the type of reimbursement (capitation global risk, capitation professional risk, capitation primary care risk, discounted fee-for-service, or fee-for-service) and whether the plan carried a clinician-withhold fund or an incentive-bonus fund. The organizational restrictiveness part of the survey included plan characterization on the following features: mental health carve-out, laboratory services, formulary, preauthorization for diagnostic or treatment procedures, preauthorization for physician referrals, specialty network, and procedure (site of service) constraints. The managed care survey features and their definitions are listed in Appendix A.*
Some plan features were viewed as more important than others for describing a plan’s financial and organizational restrictiveness. Each member of the ASPN Managed Care Task Force assigned a value of importance for each feature (using a Likert scale where 1 = somewhat important; 10 = very important). The group mean assigned weight for each feature was used to calculate the 2 weighted summary scores representing the financial and organizational restrictiveness of each plan.
In addition to the managed care plan features, clinicians completing the survey were asked to rate the degree of hassle, defined as the degree of time-consuming interference with routine practice activities perceived to be associated with the plan, on a scale of 1 to 5. Additional items on the Managed Care Survey included questions about the type of practice (solo, multispecialty group, and so forth), political/business affiliations, recent mergers/buyouts, and type of clinician compensation.
The attributes of delivery of primary care were measured by the revised Components of Primary Care Instrument (CPCI)20,21 which measures key attributes of the patient-provider relationship based on the recent Institute of Medicine definition of primary care.9 The CPCI assesses interpersonal communication, comprehensive care, continuity of care, coordination of care, provider’s accumulated knowledge about the patient, family orientation, community orientation, advocacy, and patient preference for their usual provider. Each attribute is measured from the patient’s perspective of the patient-provider relationship. Descriptive statistics, internal consistency reliabilities, and scale content are displayed in Appendix B.* Missing data on the CPCI scale scores were handled by setting a maximum number of missing values allowed per scale and computing a score using individual responses to the remaining scale items. Questionnaires missing more data than the maximum allowed were given no score for that scale. Therefore, the total number of patients with complete data per scale, and the sample size for analyses, varies by scale.
Patient satisfaction with the visit was measured using the Medical Outcomes Study 9-Item Visit Rating Form.22 Two scores were computed, patient satisfaction with the physician and with practice operation.23 Another specific patient item (satisfaction with the amount of time spent with the physician) was also assessed separately. Eight items were written to assess the patient’s perceived hassle in obtaining health care, and a summary scale score was computed (internal consistency reliability = .80). Additional items on the patient survey included patient age, sex, 2 reports of health status, whether today’s physician is the patient’s regular physician, and if no, whether the patient’s regular physician is a member of the office. Standard demographic items were included on the abbreviated survey for new patients. Also included were questions regarding whether that visit was for well-care or serious illness, and whether they had been forced to change physicians in the past 2 years.