Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures.

BACKGROUND: Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. OBJECTIVE: We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support. DESIGN: Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. PARTICIPANTS: Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. ANALYSIS: We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. FINDINGS: All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. CONCLUSIONS AND IMPLICATIONS: Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.

Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control.

Value-based purchasing of physician services aims to incentivize greater adherence to clinical practice guidelines. By increasing job demands, new reimbursement models could adversely affect job satisfaction and, indirectly, clinical performance. Studies of satisfaction-performance associations among healthcare practitioners have yielded inconsistent findings. We investigated whether physicians' perceptions of autonomy support and job control significantly moderate the relationship between practice satisfaction and guideline adherence in a pay-for-performance context. We performed secondary analysis of a study dataset created by merging prospective information on clinical services provided by Rochester (NY)-based primary physicians (N = 156) during the years 2001-2004 with census data on specific characteristics of their ambulatory-care populations, claims-sourced information on attributes of their primary care practices, and survey data on their work-related attitudes. Greater job satisfaction had a significant multivariate association with lower adherence (ß = -0.139; p=<.0001) among physicians that perceived low autonomy support from the market-dominant payer organization. For physicians experiencing high autonomy support, a positive satisfaction-adherence association existed (ß = 0.105; p=<.0001). Low job control was a negative moderator (ß = -0.103; p=<.0001), and high control a positive moderator (ß = 0.071; p=<.0001), of the influence of job satisfaction on guideline adherence. Given the limitations of this study, such as the cross-sectional survey data and potential for unmeasured confounding variables, the validity of our findings should be tested by future research. We conclude that payers attempting to over-direct partner physicians can demotivate the satisfied physicians from achieving top-level guideline adherence, thereby squandering opportunities for intrinsic satisfaction to improve guideline adherence. To optimize the potential for job satisfaction to motivate greater guideline adherence, it may be important for payers to be perceptibly more supportive of physicians' autonomy and sense of job control.

The Moderating Effect of Job Satisfaction on Physicians' Motivation to Adhere to Financially Incentivized Clinical Practice Guidelines.

We examined moderating effects of professional satisfaction on physicians' motivation to adhere to diabetes guidelines associated with pay-for-performance incentives. We merged cross-sectional survey data on attitudes, from 156 primary physicians, with prospective medical record-sourced data on guideline adherence and census data on ambulatory-care population characteristics. We examined moderating effects by testing theory-driven models for satisfied versus discontented physicians, using partial least squares structural equation modeling. Results show that attitudes motivated, while norms suppressed, adherence to guidelines among discontented physicians. Separate models for satisfied versus discontented physicians revealed motivational differences. Satisfied physicians disregarded intrinsic and extrinsic influences and biases. Discontented physicians, alienated by social pressure, favored personal inclinations. To improve adherence to guidelines among discontented physicians, incentives should align with personal attitudes and incorporate promotional campaigns countering resentment of peer and organizational pressure.

Motivators and hygiene factors among physicians responding to explicit incentives to improve the value of care.

BACKGROUND: Physician's dissatisfaction is reported to be increasing, especially in primary care. The transition from fee-for-service to outcome-based reimbursements may make matters worse. PURPOSE/OBJECTIVE: To investigate influences of provider attitudes and practice settings on job satisfaction/dissatisfaction during transition to quality-based payment models, we assessed self-reported satisfaction/dissatisfaction with practice in a Rochester (New York)-area physician practice association in the process of implementing pay-for-performance. SUBJECTS/METHODS: We linked cross-sectional data for 215 survey respondents on satisfaction ratings and behavioral attitudes with medical record data on their clinical behavior and practices, and census data on their catchment population. Factors associated with the odds of being satisfied or dissatisfied were determined via predictive multivariable logistic regression modeling. RESULTS/CONCLUSIONS: Dissatisfied physicians were more likely to have larger-than-average patient panels, lower autonomy and/or control, and beliefs that quality incentives were hindering patient care. Satisfied physicians were more likely to have a higher sense of autonomy and control, smaller patient volumes, and a less complex patient mix. Efforts to maintain or improve satisfaction among physicians should focus on encouraging professional autonomy during transitions from volume-based to quality/outcomes-based payment systems. An optimum balance between accountability and autonomy/control might maximize both health care quality and job satisfaction.

The impact of a program in mindful communication on primary care physicians.

PURPOSE: In addition to structural transformations, deeper changes are needed to enhance physicians' sense of meaning and satisfaction with their work and their ability to respond creatively to a dynamically changing practice environment. The purpose of this research was to understand what aspects of a successful continuing education program in mindful communication contributed to physicians' well-being and the care they provide. METHOD: In 2008, the authors conducted in-depth, semistructured interviews with primary care physicians who had recently completed a 52-hour mindful communication program demonstrated to reduce psychological distress and burnout while improving empathy. Interviews with a random sample of 20 of the 46 physicians in the Rochester, New York, area who attended at least four of eight weekly sessions and four of eight monthly sessions were audio-recorded, transcribed, and analyzed qualitatively. The authors identified salient themes from the interviews. RESULTS: Participants reported three main themes: (1) sharing personal experiences from medical practice with colleagues reduced professional isolation, (2) mindfulness skills improved the participants' ability to be attentive and listen deeply to patients' concerns, respond to patients more effectively, and develop adaptive reserve, and (3) developing greater self-awareness was positive and transformative, yet participants struggled to give themselves permission to attend to their own personal growth. CONCLUSIONS: Interventions to improve the quality of primary care practice and practitioner well-being should promote a sense of community, specific mindfulness skills, and permission and time devoted to personal growth.

Creating community collaboration to improve the care of patients with high blood pressure: lessons from Rochester, New York.

Over the past two years, the business community of Monroe County, which includes Rochester, New York, has been engaging in a collaborative to improve outcomes for people with high blood pressure. As the employers examined the costs of care in the community, they recognized two important factors. First, the costs of care for the uninsured, the underinsured, and the Medicare population influence the business community's cost of care. Second, trying to redesign care just for their employees alone was not effective. This project is unique in that the stimulus and funding for community-wide action comes from the business community. They saw beyond the often unsuccessful short-term cost reduction programs and joined with a community-focused organization, the Finger Lakes Health Systems Agency, to construct a multi-year, multi-faceted intervention designed to encourage practice redesign and an invigorated community commitment to partnership and accountability. This report describes the process to date and hopefully will stimulate conversations about mechanisms to encourage similar collaboration within other communities.

Lost in translation: physicians' struggle with cost-reduction programs.

Relationships between health plans and the medical profession are often strained, leading to the inability to create a shared vision for the health care redesign needed to more effectively care for our population. Because of their respective stakeholders, health plans and providers naturally differ in perspective. However, this article suggests that it is the inability of stakeholders to find a common language to effectively communicate interests, needs, and proposed interventions that often derails progress toward common goals. The business and health plan leaders' focus on cost-containment and cost-efficiency predictably results in physician defensiveness and disengagement. At the same time, physicians' limited focus on improving quality to only reducing underuse, which in the short term increases costs, does not acknowledge cost concerns of business leaders and health plan executives. However, as divergent as these emphases might seem, there is potential for common ground with effective language translation. Effective translation has been proposed through the Institute of Medicine's definition of quality as reducing overuse, misuse, and underuse. Creating a common language provides seemingly opposing groups an opportunity to explore a shared vision. Using the language of clinical appropriateness and reducing unnecessary variation has resulted in agreement on clinical quality improvement projects from which each group can return to its own organizations and translate back into its familiar "stakeholder" language.

Provider attitudes associated with adherence to evidence-based clinical guidelines in a managed care setting.

In a cross-sectional observational study of Rochester (New York) primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration, the authors investigated attitudinal factors associated with provider adherence to evidence-based clinical guidelines targeted by explicit incentives. The multivariable adherence model linked guideline adherence rates to provider attitudes among 186 survey respondents, adjusting for individual, practice, and community characteristics. Adherence was defined as the percentage of expected services that were delivered. Attitudes associated with adherence, independent of specialty and prior behavior, were financial salience (adjusted odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.7-8.4), peer cooperation (OR = 2.0; 95% CI = 1.0-4.0), control (OR = 0.5; 95% CI = 0.3-1.0), and autonomy regarding the health plan (OR = 0.3; 95% CI = 0.1-0.6). The most adherent providers perceived P4P as financially salient and felt supported by peers. Some PCPs might have perceived P4P and external interventions as challenging their autonomy and "crowding out" their intrinsic motivation, leading them to reduce efforts aimed at guideline adherence.

Beyond the efficiency index: finding a better way to reduce overuse and increase efficiency in physician care.

Current strategies for addressing health care costs stress physician performance measurement and commonly use an efficiency index (EI). During seven years of conducting individual practitioner pay-for-performance (P4P), we found that using EIs hindered our work on reducing overuse of services. This paper offers an alternative approach through the identification of variation in key cost drivers. As proof of concept, we apply this model to hypertension care. We then describe a project that decreased apparent overuse of fiberoptic laryngoscopy among otorhinolaryngologists. Focusing directly on reducing overuse improves cost efficiency without the barriers imposed by EI methodology.

Physician self-disclosure in primary care visits: enough about you, what about me?

BACKGROUND: The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated. METHODS: To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD. RESULTS: The MD-SDs included discussion of personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient's diagnosis. Seventy-three MD-SDs were identified in 38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient question. Forty-four (60%) followed patient symptoms, family, or feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to the patient topic preceding the disclosure. Most MD-SDs (n=62; 85%) were not considered useful to the patient by the research team. Eight MD-SDs (11%) were coded as disruptive. CONCLUSIONS: Practicing primary care physicians disclosed information about themselves or their families in 34% of new visits with unannounced, undetected, standardized patients. There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

Training practitioners to communicate effectively in cancer care: it is the relationship that counts.

The motivation to learn new skills that improve patient care comes from practical experience. Once motivated, trainees and practitioners alike require excellent content and process to modify approaches that improve outcomes. This paper defines content areas the authors believe are needed to improve communication between cancer patients and their practitioners. Perhaps more importantly, the educational process to achieve improved outcomes is discussed and the importance of the context in which that education occurs is stressed. The linkage between administrative behavior and practitioner behavior is described. Synchronicity between the expectations for practitioner practice and the practice environment is needed for practitioners to successfully incorporate the patient-centered practices patients are demanding. Finally, a research agenda is outlined that encourages evaluation of the model proposed.