Bringing the Physician Back In: Communication Predictors of Physicians' Satisfaction With Managed Care

Bringing the Physician Back In:Communication Predictors ofPhysicians’ Satisfaction With

Managed Care

John C. LammersDepartment of Speech Communication

University of Illinois at Urbana-Champaign

Ashley DugganDepartment of Communications

University of California at Santa Barbara

Data from a survey of physicians in a west coast city (n = 356) are used to measurephysicians’ extra-occupational sources of dissatisfaction. Data revealed a significantrelationship between physicians’ satisfaction and their managed care experience,their communication with managed care organizations, and views of managed carepractice. Results suggest that managed care currently plays a large and significant rolein predicting physicians’ satisfaction. The importance of communication betweenphysicians and managed care organizations is illustrated in the strength of the rela-tionships between communication variables and managed care decisions. Further-more, in assessing the strength of the relationship, regression analysis reveals thatcommunication with managed care accounts for the largest percentage of variance inphysicians’ satisfaction. The results of this study suggest that communication withmanaged care organizations affects physicians’ satisfaction with every facet of the or-ganizational environment, including leading physicians who report problematic com-munication with managed care organizations to say that they would be less likely tochoose the same career path again.

HEALTH COMMUNICATION, 14(4), 493–513Copyright © 2002, Lawrence Erlbaum Associates, Inc.

Requests for reprints should be sent to John Lammers, Department of Speech Communication, Uni-versity of Illinois at Urbana-Champaign, 228 Lincoln Hall, MC 456, 702 South Wright Street, Urbana,IL 61801. E-mail: [email protected]

In July 1999, the American Medical Association (AMA) announced its support forcollective bargaining for physicians, an unprecedented step for the “sovereign pro-fession” of medicine (Cunningham, Grossman, St. Peter, & Lesser, 1999; Starr,1983). One year later, the U.S. House of representatives passed legislation givingphysicians the right to negotiate jointly with health plans (Aston, 2000). Once thearchetypal professional occupation, physicians for most of the 20th century haveheld such authority, prestige, and power that other professions modeled themselvesafter medicine (Scott, 1965), and theoretical models of professions were foundedupon the American medical doctor (Freidson, 1970). Today, physicians are takingthe approach to working conditions long the way of trade and industrial workers.What could have brought the medical profession to this turn? While labor relationsscholars and historians of medicine or health policy will have their own explana-tions, this article pursues the possibility that communication between physiciansand their contracted managed care organizations explains an important proportionof physicians’ current occupational satisfaction—or dissatisfaction.

Until recently, health communication researchers have focused their attentionon issues revolving around the treatment of patients and the relationship be-tween patients and providers (Finnegan & Viswanath, 1990; Lambert et al.,1997). The communicative relationship among providers has rarely been the ma-jor focus of research. A leading exception to this generalization is Geist andHardesty’s (1992) examination of the effect of the implementation of DiagnosticRelated Groups (DRGs; an early element of Medicare managed care) on com-munication among providers and administrators in hospitals. Their study foundthat the implementation of the payment system that classifies treatments led torounds of negotiation and gaming to avoid changing the prevailing practices ofdelivering hospital services. Today, 10 years later, managed care influences notonly the health services provided in hospitals, but individual patient care in doc-tors’ offices throughout the United States as well. By 1997, 760 Health Mainte-nance Organizations (HMOs) provided services to 78 million Americans(Interstudy, 1998). In 1983, 76% of nonfederal physicians were self-employed,but by 1997 that figure had dropped to 57% (Cunningham et al., 1999). Evenphysicians who continue to be self-employed are surrounded by managed carearrangements; in 1997, 97% of all nonfederal physicians were parties to con-tracts to provide patient care through managed care firms, compared to only61% in 1990 (Cunningham et al., 1999).

Managed care is an arrangement where an insuring organization accepts therisk for providing a defined set of health services, using a defined set of providers,for a defined population, in return for a fixed or regular per capita payment(Davidson, Sofaer, & Gertler, 1992). The relationship between the insuring orga-nization and providers, the method for reimbursing providers, the amount of risk toaccept, and the extent to which enrollees have access to non-network providers,can all vary across managed care arrangements (Kongstvedt, 1995; Luft, 1987).

494 LAMMERS AND DUGGAN

For an increasing number of Americans, this is the context in which care is pro-vided and in which health communication occurs.

With regard to communication, managed care also provides boundary condi-tions where formal communication may be limited by contracts between three par-ties: a population of patients, a plan administration, and a group of providers,including physicians, hospitals, laboratories, and pharmacies (Lammers & Geist,1997). The contracts specify the qualifications of eligible patients, obligations of aplan administration, and duties of the providers in the plan (Kongstvedt, 1995).The major difference between managed care arrangements and the traditionalfee-for-service (FFS) payment method is that insurers, including the governmentoperated MediCare system, stipulate in advance the payment that providers (bothhospitals and physicians) will receive for their services, and in many cases requireadvance authorization before they will agree to pay for specialized services.

The growth in managed care involvement by physicians has until recently es-caped the notice of communication researchers. In a 1997 special issue of the jour-nal Health Communication devoted to the concept of the patient, only one articledealt with the effects of managed care (Lammers & Geist, 1997). More recently, aconference was held at Texas A&M University to confront the role that communi-cation scholars and researchers can play in the burgeoning and problematic man-aged health care arena. One goal of the present project is to direct researchers’attention to communication among providers and between providers and adminis-trators in the age of managed care.

The current study suggests that managed care plays a large and significant rolein predicting physicians’ satisfaction. Specifically, the first section below providesa review of the literature on physicians’ satisfaction. Next, based on literature re-viewed and on recent trends in health care, hypotheses about the relationship ofphysicians’ satisfaction to managed care experience, views about managed care,and communication within the managed care environment are proposed. Usingdata from a survey of physicians in a west coast city (N = 356), these hypothesesare tested, and implications for practicing medicine within the boundaries of man-aged care are provided. Suggestions for further research into the communicativelinks between managed care, providers, administrators, and patients are discussed.

PREDICTORS OF PHYSICIANS’ SATISFACTION1

When the first widespread job satisfaction studies were conducted in the 1970s,few professional occupations were included (for reviews, see Griffin & Bateman,1986; Lammers, 1992). Researchers conducting such studies assumed that profes-

PHYSICIANS AND MANAGED CARE 495

1This discussion draws extensively on Lammers, 1992.

sionals such as physicians would be more satisfied than other workers because theirincome was higher and their control over their work was greater than other occupa-tions. Eventually, when job satisfaction studies faded from scholarly interest, thegeneral conclusion was that satisfaction and productivity were only weakly associ-ated (Iaffaldano & Muchinsky, 1985; Lammers, 1992; Petty, McGee, & Cavender,1984). Now, as the economy has become dominated with service occupations, andespecially more recently as the United States has approached full employment, thecausesandeffectsofworkersatisfactionmaybereturning to theresearchagenda.

In a comprehensive review of the work satisfaction literature, Griffin and Bate-man (1986) found satisfaction to be related to job design, demographic factorssuch as income, age, and education (but typically not race or sex), reward systems,leadership, and participation. They also found consistent patterns of meaningfulrelationships between a variety of organizational characteristics and individual jobsatisfaction (Griffin & Bateman, 1986). These characteristics include vertical andhorizontal power distributions, increased division of labor, standardization, com-munication, work scheduling, and privacy (Griffin & Bateman, 1986).

But professional occupations like medicine continue to develop their own tradi-tions of attitudes toward work (Freidson, 1970, 1985; Reames & Dunstone, 1989).The literature on physicians’ satisfaction reveals five general themes, each ofwhich is communicative in nature: (a) relations with patients, (b) control over thepractice of medicine, (c) relations with colleagues and others besides patients, (d)rewards of practice, and (e) differences between younger and older practitioners.Each of these themes is discussed in greater detail.

Relationships With Patients

Suchman, Roter, Green, and Lipkin (1993) identified four sources of physicians’satisfaction related to communication with patients: (a) commitment to the pa-tient–physician relationship, (b) the data collection process, (c) the appropriate useof time during periods of contact, and (d) working with cooperative, nondemandingpatients. Physicians reported that they want time to develop relationships with pa-tients, and that the strength of the patient–physician relationship is highly corre-lated with physicians’ satisfaction (Suchman, Roter, Greer, & Lipkin, 1993). Forexample, physicians who reported the lowest satisfaction were those not working inHMOs but having a large percentage of patients with capitated reimbursements(Bates, Harris, Tierney, & Wolinsky, 1998). Physicians were also dissatisfied withstress-related aspects of day-to-day practice, such as workload and patient volume(McMurray et al., 1997). More specifically related to relationships with patients,physicians reported greater satisfaction when they saw the types of patients theywanted to see (Silverstein & Kirkman-Liff, 1995). Family physicians in particularwere more concerned with building interpersonal relationships with their patients


(Xu, Brigham, Veloski, & Rodgers, 1993). Managed care also promotes increasingthe number of patients a provider sees. This too affects communication with pa-tients, as patient volume and workload are stress-related aspects of physicians’day-to-day practices (McMurray et al., 1997).

Control Over the Practice of Medicine

Autonomy in clinical decision making is another important source of physicians’satisfaction (Bates, Harris, Tierney, & Wolinsky, 1998). Managed care has beenaccused of removing this source of satisfaction from physicians. Physicians whowere concurrently seeing patients in a general and HMO-affiliated practice rated allaspects of medical practice, except paperwork, lower for HMO practice in compar-ison to general practice (Deckard, 1995). However, purely HMO-affiliated physi-cians have been found to be just as satisfied as physicians in general practice(Deckard, Meterko, & Field, 1994). In support of this finding, a study of physiciansin 1993 found more satisfaction with HMO work situations and less satisfactionwith FFS practices (Schulz, Scheckler, Moberg, & Johnson, 1997). As new doctorsenter the field resistance to innovations in the management of health services maybreak down.

Relations With Colleagues and Others Besides Patients

Extra-organizational factors (e.g., government regulations, competition from indi-viduals and groups) that are beyond the control of individual practitioners also in-fluence physicians’ job satisfaction (Burdi & Baker, 1997; Donelan, Blendon,Lundberg, & Calkins, 1997; Lammers, 1992). One doctor who began practicing af-ter the implementation of HMOs reported: “The pressure is to see more patients tomaintain income. It hasn’t compromised the quality of care yet, but it does cut intooverall satisfaction. So many external forces are disrupting that relationship and thepractice of medicine. Physicians’ satisfaction is eroding” (Haley, 1998, p. 19, em-phasis added).

Relationships with colleagues also affect physicians’ satisfaction (Bates, Har-ris, Tierney, & Wolinsky, 1998; McMurray et al., 1997). Administrative arrange-ments have been found to influence physician practices, especially with regard tomanaged care contracts (LePore & Tooker, 2000). Dissatisfaction with the referralprocess results when patients arrive at a specialist’s office and neither the patientnor the specialist knows exactly why the primary care provider (PCP) sent the pa-tient, or a patient returns to a PCP with insufficient notes from the specialist(Cybulska & Rucinski, 1989). Similarly, physicians who perceive themselves ashaving more participation in the decision making process of managed care organi-


zations also tend to be more satisfied with their work (Barr & Steinberg, 1983;Deckard, Meterko, & Field, 1994; Silverstein & Kirkman-Liff, 1995).

Rewards of Practice

According to the U.S. Department of Labor, physicians have among the highestearnings of any occupation. Median income, after expenses, for allopathic physi-cians was about $160,000 in 1995. The middle 50% earned between $115,000 and$238,000, compared to the U.S. average annual earnings in 1999 of $27,196 (Pilot,1999). Self-employed physicians—those who own or are part owners of their medi-cal practices—had higher median incomes than salaried physicians.

The practice of medicine also involves less tangible rewards. A comparison ofphysicians across specialties revealed that all were concerned with the lack of per-sonal time afforded by their occupation (Xu, Brigham, Veloski, & Rodgers, 1993).Medical school graduates today may have different priorities than doctors in thepast. Specialties that allow physicians more control over their work hours are be-ing chosen more and more by medical students (Schwartz et. al., 1989). However,nearly 10 years later, Schulz, Scheckler, Moberg, and Johnson (1997) found pri-mary care physicians to be more satisfied than subspecialists, suggesting that prac-ticing under an HMO structure may provide different rewards.

Differences Between Younger and Older Practitioners

Predictors of physicians’ satisfaction change as new physicians with new expecta-tions enter the health care system. New physicians who are learning the managedcare system as their first health care provider arrangement may be less resistant tothe new ways of managing the practices and find sources of satisfaction within themanaged care system. Studies of young physicians find different predictors of sat-isfaction than studies which sample physicians of all ages (Baker, Cantor, Miles, &Sandy, 1994). For example, time pressures and competence concerns are cited asstronger sources of stress for young doctors (Simpson & Grant, 1991). Older physi-cians have been found to be less satisfied than young physicians (Bates, Harris,Tierney & Wolinsky, 1998; McMurray et al., 1997). Consistent with high satisfac-tion for younger physicians, Xu and Veloski (1998) reported that physicians whograduated from medical school in 1983 or 1984 (and had limited experience beforehealth care changes with managed care) were very satisfied with practicing medi-cine, with 94% saying they were satisfied with their specialty choice. However,Haley (1998) provides evidence that young doctors may not be as satisfied as otherresearch may have suggested. In that study, 35% of physicians practicing less than10 years say they would not become physicians again if they had the choice to make


again. The other two thirds of young California physicians participating in thestudy stated that they felt fulfilled by their work; 88% were satisfied with their phy-sician–patient relationships. Only 61% were satisfied with their referral arrange-ments and 68% with control of clinical decision making (Haley, 1998).

Sources of job-related stress may vary among younger and older physicians.Simpson and Grant (1991) found four sources of job stress that could affect satis-faction for young physicians: patient relationships, business/financial issues, timepressures, and competence concerns. Recent graduates were concerned with busi-ness and financial issues, and especially with paying back student loans with in-comes that have decreased significantly in the past two decades. Xu and Veloski(1998) found that debt at the time of graduation correlated with primary care phy-sicians’ career satisfaction. New graduates tend to want a salary immediately upongraduation, which often means becoming an employee of an HMO (or a well-es-tablished large group practice that relies on managed care contracts), rather thanstarting their own practices and struggling financially. HMO physicians are morelikely to think a physician surplus is emerging and that HMOs offer better workingarrangements (Ferraro, 1993).

The foregoing literature leads us to hypothesize that physicians’ exposure to,attitudes about, and communication with managed care organizations are all re-lated to their work satisfaction. Our first hypothesis (H) therefore concerns thestructural aspects of the relationship between physicians’ satisfaction and man-aged care:

H1: Physicians’ exposure to managed care (measured by number of con-tracts, percentage of patients who use FFS payment method, and yearsof practice) is negatively related to physicians’ satisfaction.

This H simply argues that because of the contradictions between managed careand medical practice, more exposure leads to less satisfaction. Younger physi-cians, those with fewer managed care contracts, and those with higher percentagesof fee-for-service patients should all report higher satisfaction.

The next five Hs each deal with aspects of the literature reviewed above (auton-omy, relations with patients, their choice of profession, relations with managedcare, and satisfaction with their present position):

H2: Physicians’ satisfaction with the limits on their clinical autonomy isnegatively associated with their reports of communication problemsand positively associated with their views of the practice of medicine.

H3: Physicians’ satisfaction with the types of patients and problems theytreat is negatively associated with their reports of communicationproblems and positively associated with their views of the practice ofmedicine.


H4: Physicians’ satisfaction with their choice of profession is negativelyassociated with their reports of communication problems and posi-tively associated with their views of the practice of medicine.

H5: Physicians’ satisfaction with their contracted managed care organiza-tions is negatively associated with their reports of communication prob-lems and positively associated with views of the practice of medicine.

H6: Physicians’ satisfaction with their present position is negatively asso-ciated with their reports of communication problems and positivelyassociated with their views of the practice of medicine.

In contrast to the first H, which explores the relationship between exposureand satisfaction, H2 through H6 explore the correlates of satisfaction more spe-cifically.

RESEARCH DESIGN AND METHODS

Two steps were employed in the data collection strategy. First, personal interviewswith physicians were conducted (n = 6) in various specialties and practice arrange-ments in order to become acquainted with prevalent issues in the local medical caresystem. These interviews lasted from 30 min to 1.5 hr. In addition, one physicianwhose job includes managing a group practice permitted observations of his work.

In the second step, a questionnaire on physician satisfaction in the workplacewas mailed to all practicing local physicians in a West coast city with a total popu-lation of 150,000. The questionnaire was adapted from a similar study of satisfac-tion with medical practice (Lammers, 1992). The questionnaire was altered toinclude questions significant to the current local medical care system. A review ofmore recent literature also led us to add several questions in order to make the re-sults representative of all highly impacted managed care environments. FollowingDillman (1978), the questionnaire consisted of 43 items grouped by category withnarrative and instructive headings in each section.

The questionnaire was mailed to a saturation sample of 644 doctors obtainedfrom the rosters of the two major medical groups in the city and the membershiplist of the county medical society. Of the sample total, 14.1% were women and85.9% were men. Two follow up mailings yielded a crude response rate of 60.2%(388 questionnaires returned). After subtracting 29 respondents and their returnedquestionnaires because of wrong addresses or receipt of replies indicating that therespondent no longer practiced medicine, the final response rate totaled 63.1%.The data were analyzed using SPSS for Windows (Release 9.0.0).

Respondents and nonrespondents appeared to be similar. Both groups includedsimilar percentages of primary care practitioners, specialists, and women, and sim-ilar percentages were associated with major local medical organizations (see Table


1). In addition, 68.3% of the respondents had graduated from medical school in1982 or earlier; and 81.4% had begun seeing managed care patients during 1983 orlater. Researchers judge respondents to yield a generalizable sample.

RESULTS

Data Reduction

To group smaller sets of composites, increase reliability and minimize Type I errors(by reducing the number of statistical tests), principal axes factor analysis usingoblique rotation (which does not assume the absence of measurement error) wasconducted separately on (a) reports of problems with communication and (b) viewsof practicing medicine. Criteria for factor and item retention were (a) eigenvaluesgreater than 1.0 for retained factors, (b) primary factor loading scores of .50 orbetter, (c) presence of two or more items with primary loading scores, and (d)interpretability of the resulting factor structure. Items with secondary factor load-ing of .30 or greater were only retained in the case where it was theoretically centralto the factor and its primary loading. Internal consistency within factors was furtherassessed through reliability analysis using Cronbach’s alpha.

Reports of problems with communication. The first rotated factor analy-sis produced as the best solution three factors, accounting for 54.2% of the varianceof reports of problems with communication. The three factors and their coefficientalphas are as follows. The first factor, which measured reports of problems withcommunication with patients, includes demanding patients, physician–patient rela-tionships, communication with patients, communication regarding patient consul-tations, and relationships between primary care practitioners and specialists (α =.68). The second factor, reports of problems with communication regarding regu-lations, includes paperwork, keeping up with guidelines and regulations, the num-ber of patients seen each week, work hours, and formularies (α = .75). The third fac-tor, reports of problems with communication regarding managed care, includes


TABLE 1Comparison of Respondents and Nonrespondents by Area, Group Association, and Sex

Category Respondents (%) Nonrespondents (%)

Primary care 28.7 27.6Specialists 71.3 72.4Association with major local medical organizations 43.5 36.5Female 14.0 18.5

compensation, income, relationships with managed care administrators, communi-cation with managed care administrators regarding patient care, and competitionfrom new organizations (α = .82).

Views of Practicing Medicine

The rotated factor analysis produced as a best solution four factors, accounting for42% of the variance of views of practicing medicine. The first factor, rewards, in-cludes the beliefs that the practice of medicine is more satisfying today than it oncewas, that earnings relative to other occupations are appropriate, having the author-ity to make necessary clinical decisions, having adequate time to answer and ex-plain questions to patients, and having a satisfactory amount of personal time (α =.63). The second factor, importance of controllable work hours, included twoitems: the importance of controllable work hours in choosing the field of practiceand the importance of controllable work hours in the current work situation. Thethird factor, perceptions of control over the practice, includes beliefs that competi-tion between local physicians is growing, physicians can do better as solo practitio-ners, practicing in large organizations compromises physicians’ integrity, physi-cians compete with other organizations for control over patient care, and physiciansneed to work together to protect their economic interests (α = .47). The fourth fac-tor, healthy competition, includes beliefs that physicians have a strong sense of col-legiality with one another and competition between local physicians is healthy (α =.48). The latter two factors are regarded as only marginally useful for the purposesof exploratory research, and therefore were excluded from further analysis(Nunnally, 1970).

Single-Item Independent Variables

Single item independent variables included year of graduation from medicalschool, the number of managed care organizations contracted, the percentage of pa-tients using the fee-for-service payment method, and the year the physician first be-gan seeing managed care patients. We also included as a single-item independentvariable the physician’s perception that someone monitors the practice other thanhimself or herself.

One problem that emerges in studying physicians’ satisfaction is that becausephysicians do have so much involvement in and control over their work, commu-nication elements and sources of satisfaction are likely to be highly correlated. Re-searchers typically recommend multiple indicators of satisfaction rather than justone measure (Ironson, Smith, Brannick, Gibson, & Paul, 1989). For that reason weincluded multiple items by which to measure job satisfaction.


Physician Satisfaction

Satisfaction was measured using five variables: (a) satisfaction with choice of pro-fession, (b) satisfaction with present position, (c) satisfaction with contracted man-aged care organizations, (d) satisfaction with limits on clinical autonomy, and (e)satisfaction with types of patients and problems treated (see Table 2 for statistics ondependent and independent variables).

Exposure to Managed Care

The first H predicted that physicians who had greater exposure to managed carewould be less satisfied with their work situations. This was tested using Pearsonproduct–moment correlations. Exposure to managed care was measured in terms ofyear of graduation from medical school, the number of managed care organizations(HMOs, PPOs, etc.) the physician contracted, and the percentage of the physicians’patients using the FFS payment method.

H1 was supported. Year of graduation, number of contracts with managed careorganizations, and percentage of patients using the FFS method of payment allcorrelated communication issues in medical practice (see Table 3). Physicianswho graduated from medical school more recently report more frequent problemsof communication with patients (r = .13, p < .05). Physicians who graduated frommedical school more recently also report controllable work hours as a more impor-tant factor in choosing medicine as their profession (r = .19, p < .001).

More importantly, the number of contracts with managed care organizationsprovided evidence of the negative relationship between physician exposure tomanaged care and communication problems, as well as a negative relationshipwith physicians’ satisfaction (see Table 4). Physicians who reported having morecontracts with managed care organizations also reported more problems with com-munication regarding regulations (r = .20, p < .001); more problems with commu-nication with managed care organizations (r = .22, p < .001); and more negativeviews of the rewards of practicing medicine (r = –.15, p < .01).

Similarly, physicians who reported a larger percentage of patients who usethe FFS method of payment reported fewer problems with communication withpatients (r = –.18, p < .01); fewer problems with communication regarding regu-lations (r = –.24, p < .001); and fewer problems with their managed care organi-zations (r = –.17, p < .01). Physicians who had a greater percentage of patientsusing the fee-for-service method of payment also viewed the practice of medi-cine as more rewarding (r = .26, p < .001).

Physicians reported greater satisfaction with their choice of profession whenthey reported fewer contracts with managed care organizations (r = –.11, p < .05);similarly, they reported greater satisfaction with their choice of profession when


the percent of fee-for-service paying patients was higher (r = .12, p < .05). Physi-cians also reported greater satisfaction with their present position when the percentof fee-for-service patients was higher (r = .16, p < .05).

Physicians’ Satisfaction

The second set of hypotheses (H2 through H6) predicted that physicians’ satisfac-tion was negatively associated with reports of communication problems and posi-tively associated with views of practicing medicine as rewarding. Hypotheses twothrough six were tested using hierarchical multiple regression analysis with the or-der of predictors entered based on the strength of the correlation. Physicians’ satis-faction as a dependent variable was measured in terms of satisfaction with specificaspects of practicing medicine (each predicted in a single H), including satisfactionwith limits on the physicians’ clinical autonomy (H2), satisfaction with the types of


TABLE 2Means, Standard Deviations, and Ranges for Independent and Dependent Variables

M SD Minimum Maximum

Communication and perception variablesReports of problems withcommunication with patients

1.90 .66 1.00 3.75

Reports of problems withcommunication regarding regulations

2.80 .86 1.00 5.00

Reports of problems withcommunication with managed careorganizations

2.61 .95 1.00 5.00

Perceptions of greater rewards ofmedicine

2.86 .79 1.20 5.00

Practice is monitored by someone else 2.05 .61 1.00 3.00Continuous variables

Graduation year (from medical school) 1976.78 10.35 1944 1996Number of contracts with managed careorganizations

8.48 10.00 .00 65%

Percent of patients using fee-for-servicepayment method

37.00 32.08 .00 100%

First year contracted with managed careorganizations

1977 157.37 .00 1998

Satisfaction variablesSatisfaction with limits 2.33 1.13 1.00 5.00Satisfaction with patients and problems 4.03 .64 2.00 5.00Satisfaction with choice of profession 2.41 .83 1.00 3.00Satisfaction with managed Care 1.81 .84 1.00 4.00Satisfaction with present position 2.99 .98 1.00 4.00

Note. N = 356.

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TABLE 3Coefficients of Correlation Between Experience With Managed Care,

Reports of Communication Problems, Views About Medicine, andSatisfaction With Practicing Medicine

Communication-RelatedFactor

GraduationYear

No. of ContractsWith Managed Care

Organizations

Percent of PatientsUsing Fee-For-Service

Payment Method

Reports of problems withcommunication withpatients

.13* .09 –.18**

Reports of problems withcommunication regardingregulations

–.01 .20*** –.24**

Reports of problems withcommunication withmanaged careorganizations

.01 .22*** –.17**

Perceptions of greaterrewards of medicine

–.05 –.15** .26**

Importance of controllablework hours

.19*** –.08 –.01

Satisfaction with presentposition

–.02 –.07 .12*

Satisfaction with choice ofprofession

.03 –.11* .16*

*p < .05. **p < .01. ***p < .001.

TABLE 4Coefficients of Correlation Between Communication Variables and Physicians’ Satisfaction

Reports of Problems With Communication Perceptionsof GreaterRewards ofMedicinePhysicians’ Satisfaction

WithPatients

RegardingRegulations

With ManagedCare Organization

Satisfaction with limits –.22** –.40** –.49** .45**Satisfaction with problems and

patients–.33** –.22** –.24** .29**

Satisfaction with choice ofprofession

–.23** –.31** –.35** .41**

Satisfaction with managed careorganizations

–.14* –.32** –.51** .42**

Satisfaction with present position –.24** –.42** –.49** .48**

*p < .01. **p < .001.

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TABLE 5Hierarchical Multiple Regression of Physicians’ Satisfaction on Communication Variables

Order of Entry of IndependentVariables r RSQ ∆RSQ b F Ratio p

On satisfaction with limitsReports of problems withcommunication with managedcare organizations

–.49 .26 .26 –.51 92.81 .000


.45 .30 .04 .36 57.15 .000

Percentage of fee-for-servicepatients

–.03 .33 .03 –.01 43.58 .001

On satisfaction with patients andproblemsPerceptions of greater rewards ofmedicine

.29 .06 .06 .20 18.53 .000

Reports of problems withcommunication with patients

–.33 .09 .03 –.17 13.95 .003

Number of contracts withmanaged care organizations

.04 .11 .02 .01 10.82 .040

On satisfaction with choice ofprofessionPerceptions of greater rewards ofmedicine

.41 .16 .16 .42 50.74 .000

Reports of problems withcommunication with managedcare organizations

–.35 .19 .03 –.20 31.99 .001

Control of work hours as moreimportant

–.07 .21 .02 –.10 23.59 .017

Practice being monitored bysomeone else

–.20 .22 .01 –.18 19.43 .018

On satisfaction with managed careorganizationsReports of problems withcommunication with managedcare organizations

–.52 .27 .27 –.47 117.66 .000


.42 .31 .04 .21 68.49 .000

Percentage of patients usingfee-for-service payment

–.09 .34 .03 –.21 54.55 .000

On satisfaction with presentpositionPerceptions of greater rewards ofmedicine

.48 .24 .24 .62 85.60 .000

Reports of problems withcommunication with managedcare organizations

–.49 .28 .04 –.30 54.65 .000

patients and problems treated (H3), satisfaction with medicine as a choice of pro-fession (H4), satisfaction with contracted managed care organizations (H5), andsatisfaction with the physician’s present position (H6). Predictor variables in-cluded reports of problems with communication, views about the rewards of prac-ticing medicine, and the extent to which the physician has control over the practice.Separate regression analysis was conducted on each of the five measures of physi-cians’ satisfaction (see Table 5).

With regard to physicians’ satisfaction with the limitations on their clinical au-tonomy, three predictors accounted for 33% of physicians’ satisfaction, overallF(3, 269) = 92.81, p < .0001. Lower reports of problems communicating withmanaged care organizations (r = –.49, B = –.51, p < .001); more positive views ofrewards associated with practicing medicine (r = .45, B = .36, p < .001); and fewerfee-for-service patients (r = –.03, B = –.01, p < .05) were associated with greaterphysicians’ satisfaction concerning their clinical autonomy.

With regard to physicians reporting that they more frequently worked with thekinds of patients that interested them, three predictors accounted for 11% of physi-cians’ satisfaction, overall F (3, 276) = 18.53, p < .0001. More positive views of re-wards associated with practicing medicine (r = .29, B = .20, p < .001); decreasedreports of problems with communication with patients (r = –.33, B = –.17, p < .01);and increased contracts with managed care organizations (r = .04, B = .01, p < .05)were associated with greater physicians’ satisfaction with the types of problemsand patients they treated.

With regard to physicians reporting satisfaction with their choice of profession,four predictors accounted for 22 % of physicians’ satisfaction, overall F(4, 273) =50.74, p < .0001. More positive views of rewards associated with practicing medi-cine (r = .41, B = .42, p < .0001); decreases in reports of problems with communi-cation with managed care organizations (r = –.35, B = –.20, p < .001); reports ofcontrollable work hours being less important in the work situation (r = –.07, B =–.10, p < .05); and reports of the practice being less monitored by another person (r= –.20; B = –.18, p < .05) were associated with greater physicians’ satisfactiontheir choice of profession.

Concerning physicians reporting satisfaction with their contracts with managedcare organizations, three predictors accounted for 40% of physicians’ satisfaction,overall F(3, 311) = 54.55, p < .0001. Fewer reports of problems with communica-tion with managed care organizations (r = –.52, B = –.47, p < .0001); perceptionsof greater rewards associated with practicing medicine (r = .42, B = .21, p < .0001);and having fewer FFS patients (r = –.09; B = –.21, p < .001) were associated withgreater physicians’ satisfaction with their managed care organizations.

Finally, concerning physicians reporting satisfaction with their present posi-tion, two predictors accounted for 28% of physicians’ satisfaction, overall F(2,276) = 65.60, p < .0001. More positive views of rewards associated with practicingmedicine (r = .48, B = .62, p < .0001); and fewer reports of problems with commu-


nication with managed care organizations (r = –.49, B = –.30, p < .001) were asso-ciated with greater physicians’ satisfaction with their present position.

DISCUSSION

This work serves to substantiate previous findings while extending the notion thatphysicians’ satisfaction is highly impacted by their relationships with managedcare contracts. The importance of communication with managed care is illustratedin the strength of the relationships between communication variables and managedcare decisions. Furthermore, in assessing the strength of the relationships, regres-sion analysis reveals that communication with managed care accounts for the larg-est percentage of variance in physicians’ satisfaction. While our data do not supporta causal interpretation, the results of this study suggest that communication withmanaged care organizations impacts physicians’ satisfaction with every facet oftheir organizational environment, including leading physicians who report prob-lematic communication with managed care organizations to say that they would beless likely to choose the same career path again.

The H1 predicted that physicians who had more experience with managedcare organizations would be less satisfied with their work experiences. Exam-ining the relationship between experience with managed care and communica-tion with patients and with the managed care organizations reveals that greaterexperience with managed care is associated with restrictions on communica-tion both in the physician–patient relationship and in the organizational envi-ronment. Physicians who graduated from medical school more recently reporta much greater likelihood of problematic communication with patients. Morerecent medical school graduates report greater importance of controllable workhours both in choosing their field of practice and in their current work situa-tion. Furthermore, examining the cross-sectional data, as the number of con-tracts with managed care organizations increase, physicians more frequentlyreported more problematic communication regarding regulations of the prac-tice, more problematic communication with managed care organizations as awhole, and fewer rewards of practicing medicine. Likewise, as the percentageof a physicians’ patients who use the FFS method of payment increases, physi-cians report fewer communication problems with patients, fewer communica-tion problems regarding regulations of the practice, fewer problems withcommunication with managed care organizations, and more rewards associatedwith practicing medicine.

Physicians report greater satisfaction with medicine as a choice of professionwhen they have fewer contracts with managed care organizations and a greaterpercent of FFS patients. Relatedly, physicians who have more FFS patients aremore satisfied with their present positions. These findings tend to support the press


reports (Aston, 2000) that indicate physicians’ dissatisfaction is leading to union-ization of the occupation.

H2 through H6 predicted that physicians would be more satisfied when they re-ported fewer communication problems with their patients or their managed care or-ganizations and when they had more positive views about the rewards associatedwith practicing medicine. Although communication problems in general would ob-viously lead to dissatisfaction, the current study shows that reports of communica-tion with managed care provide a statistically significant (and theoreticallyimportant) negative contribution to physicians’ overall satisfaction.Again, in cross-sectional terms, managed care experience reduces physicians’ satisfaction withclinical autonomy, with the types of patients and problems, with choice of profes-sion, with the present position, and with managed care organizations. The strongnegative relationship between communication with managed care and physicians’overall satisfaction with managed care organizations illustrates the difficulties inpracticing medicine under the conditions imposed by managed care.

Rewards associated with practicing medicine also provided important contribu-tions to every measure of physicians’ satisfaction. Physicians who perceive the re-wards of practicing medicine as more positive are more satisfied with their workoverall.

Physicians who report greater satisfaction with the types of patients and prob-lems they deal with also report fewer problems communicating with patients.When compared to physicians’ exposure to managed care, this suggests that man-aged care may impose restrictions on communication with patients. Under themanaged care system, physicians are often encouraged to see a larger volume ofpatients, for example, restricting the amount of time spent with any one patient todiscuss possibilities for alternative treatment (Lammers & Geist, 1997). This find-ing extends previous work suggesting that the mutuality model of provider–patientcommunication leads to increased patient satisfaction (Suchman et al., 1993).

Competing for control over the practice of medicine also predicts physicians’satisfaction, especially with regard to satisfaction with managed care organiza-tions. Physicians who say someone else monitors their practice are less satisfiedwith choosing medicine as a profession. In sum, these data support arguments thatchanges brought about by managed care appear to be eroding physicians’ profes-sional autonomy.

Several methodological concerns should be noted. First, this study is explor-atory and should not be interpreted as a causal analysis or argument. We have notcaptured the full range of kinds of communicative behaviors characteristic of phy-sician-managed care communication or controlled for all of the likely correlates ofphysician-managed care communication. Also, we have explored severalintercorrelated phenomena, including reports of satisfaction, perceptions of prob-lems, and views of practicing medicine. Perhaps most importantly, our data as col-lected simply do not support a causal interpretation.


In addition, this research has highlighted the relative absence of a theory ofthe relationship between professionals like physicians and work circumstancessuch as managed care. Future iterations of this research can improve not onlyour measurement of satisfaction but also our measures of the specific kinds ofcontracts and fiscal arrangements under which physicians practice (see Marmor& Hacker, 1999). Also, our research studied only medical doctors; the managedcare movement also affects other health occupations and professions. Finally,this project only begins to skim the surface of the communication issues thatwould be important to address in order to make managed care more palatable topractitioners and patients.

More frequent reports of problems with communication with managed care andwith communication with patients under managed care suggest important implica-tions for the provider–patient relationship. The importance of encouraging patientparticipation in the medical interaction has been supported in medical research, es-pecially as physicians shift from a biomedical model, where they treat symptomsand signs of malfunction in the body, to a more psychosocial model, where thephysician and patient may address the role of culture, as well as perceptions of selfand self-reflection to come to a mutual understanding of how to deal with illness.Under the restrictions of managed care, communication seems to be shaped interms of commercial and legal issues, as influenced by the agenda of the managedcare organizations (Green, 2002). Future research should address the extent towhich physician–patient discourse and physicians’ views can be addressed withinthe context of managed care.

Finally, the research reported here offers evidence that patient–provider com-munication today occurs in a new context, namely the managed care environment.Understanding the motivations, concerns, and constraints on physicians in thiscontext should yield significant advances in understanding health communicationas a whole (for a comparison case in mental health, see Ware, Lachicotte,Kirschner, Cortes, & Good, 2000). Therefore we suggest the following items beplaced on the health communication research agenda. First, additional research isneeded to understand more precisely the relationship between physicians’ workcircumstances and their relations with patients. In particular, observational studiesshould take into account the physicians’ awareness of the patients’ paymentmethod, their attitudes toward those methods, the time constraints managed careplaces on the medical interview, and the contractual requirements the physicianfaces when choosing to recommend treatments or disclose alternatives to patients.Second, we need to conduct additional studies of physicians and others interac-tions with managed care administrators to understand how the present health carecontext is being socially constructed (Geist & Hardesty, 1992). Lastly, communi-cation scholars can make a contribution to policy development by informing thefield of health services research not only about the patient–provider dyad but theprovider–organization interface as well.


ACKNOWLEDGMENTS

This study was supported in part by a grant from the Robinson-May Foundation tothe first author. The authors wish to thank Amy John for her diligent work on an ear-lier version of this article. We also greatly appreciate the helpful suggestions onearlier drafts provided by Donald Cegala, Theodore Marmor, and two anonymousreviewers.

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