The Attitudes of Physicians toward Health Care Cost-Containment Policies Leighton Ku and Dena Fisher This study analyzed physician attitudes toward a variety of health care costcontainment policies, based on a national survey of 500 practicing doctors in 1984. Reactions to 23 policies were simplified to nine common themes usingfactor analysis. Although there was great diversity in views, physicians generallyfavored policies that increased responsibilities or costs for patients and disfavored policies that decreased physicians'autonomy ofpractice. For most policies, practice characteristics (specialty; type of practice, e.g., solo or group, salaried or self-employed; membership in medical societies; or percent of time in direct patient care) were not significant determinants of attitudes. Physicians who were more "conservative" with respect to the health care system tended to favor policies that shifted cost to patients, while more 'liberal" doctors were more supportive of using prepaid health care, reducing the intensity of care, or selecting efficient providers. Overall, this study indicates that physicians still place a high value on their professional autonomy.
In a booklet called Physician's Cost Containment Checklist, the American Medical Association (AMA) (1985) has described this current period as one of "turbulent times for the medical profession." In order to contain inflation in health care costs, for over a decade insurers, businesses, and government have sought to make health care more efficient and to change the way doctors practice medicine. Buffeted by powerful economic and social forces, American physicians are losing their tradiThis work was supported in part by a grant from the Pew Memorial Trust. Address correspondence and requests for reprints to Leighton Ku, Systemetrics/ McGraw-Hill, 24 Hartwell Avenue, Lexington, MA 02173. Dena Fisher is with Continuing Care Consulting, Goldens Bridge, NY. This work was conducted when the authors were Pew Health Policy Fellows at the Health Policy Institute, Boston University and the Heller School, Brandeis University, respectively.
26
HSR: Health Services Research 25:1 (April 1990, Part I)
tional sovereignty and dominance of the medical care system (Starr 1982; Freidson 1970; McKinlay and Stoeckle 1988; Colombotos and Kirchner 1986). Physicians, who once spoke with unquestioned authority, now find their decisions challenged by administrators. Further signs of metamorphosis are the decreases in solo fee-for-service practice as doctors increasingly join group practices, health maintenance organizations (HMOs), independent practice associations (IPAs), and preferred provider organizations (PPOs). Anecdotal reports state that "doctors are in a state of fear" (Hanna 1988) and that they are asking whether it is still a privilege to be a doctor (New England Journal of Medicine 1986), but there are almost no surveys of physician attitudes available in the published literature. This article seeks to examine physician attitudes to 23 costcontainment measures, based on a 1984 survey conducted by Louis Harris and Associates for the Equitable Life Assurance Society of the United States (now Equicor) (1983, 1984). The analyses seek to answer:
* What policies are favored and disfavored by physicians? More important, what are the common themes underlying their attitudes? * What practice characteristics are associated with differing attitudes? For example, do primary care physicians differ from specialists or solo doctors from group practice doctors? We discuss these findings in the context of how physicians' attitudes develop and change over time. Finally, we examine how these attitudes may interact with the interests of the public and payers in shaping health care policy.
METHODOLOGY The Equitable Healthcare Survey II: Physicians'Attitudes Toward Cost Containment (1984) was based on a national telephone survey of 500 practicing physicians conducted in January and February 1984. The sampling frame was derived from an AMA master file, which included both AMA members and nonmembers. To attain a final sample of 500, 2,500 physicians were randomly selected and clustered by region in groups of five names. If the first person could not be contacted or would not participate, the interviewer contacted another from the cluster until a respondent was found. Louis Harris and Associates report a response rate of 55 percent, which is within the normal range for phone
Physicians and Cost Containment
27
surveys of physicians (Taylor 1989). Respondents received a token payment in compensation for their time, among other efforts made to reduce nonresponse. Table 1 describes the sample of physicians. Although the overall sample of physicians is nationally representative, the number of physicians in any particular group, such as surgeons or HMO doctors, is relatively small. Thus, findings about a given specialty may not be generalizable to the nation.
Table 1: Description of the Physicians in the Sample (N= 500) Characteristic Primary Specialty Family practice General practice Internal medicine Obstetrics/Gynecology Pediatrics Anesthesiology Radiology/Pathology Psychiatry Other medical specialties Surgery, all types Other Primary type of practice Solo or expense-sharer Group self-employed Group salaried Hospital staff HMO staff Other Not stated American Medical Association Member Nonmember Not stated State Medical Society Member Nonmember Not stated Percent of time spent in direct patient care
Number
Percent
66 18 61 48 34 27 56 43 76 58 13
13.2 3.6 12.2 9.6 6.8 5.4 11.2 8.6 15.2 11.6 2.6
217 131 56 46 13 32 5
43.4 26.2 11.2 9.2 2.6 6.4 1.0
266 232 2
53.2 46.4 .4
401 97 2 Mean 79
80.2 19.4 .4 Standard Deviation 19
28
HSR: Health Services Research 25:1 (April 1990, Part I)
The overall survey examined issues regarding health care cost containment and the U.S. medical care system, including perceived reasons for health care cost inflation, priorities for change in the system, and the like. It paralleled a prior Equitable/Louis Harris survey of the public, business executives, insurers, and others of issues regarding the American health care system (The Equitable Life Assurance Society of the United States 1983). Of particular interest in this analysis were questions about the acceptability of 23 policies (which will be discussed in more detail later) that were coded as: 1.- very acceptable, 2- somewhat acceptable, 3- not very acceptable, and 4- not at all acceptable. Appendix A states the wording of the questions analyzed in this article. The 23 policy options were based on Equitable's perceptions of the dominant health care cost-containment options under discussion in 1984. A list drawn today would be quite similar. The analysis in this article has two major parts. First, factor analysis was used to summarize the information regarding the 23 policies and to identify the common themes in the responses. Principal components factor analysis and varimax rotation were used. A variety of models were examined; the final models were selected on their technical merits, such as percent of variance explained, and on the intuitive sensibility of the factors. After the factors were derived, factor scores were computed as the mean of the variable scores that had factor loadings greater than 0.4. Thus, they are composite scores for the factors most influential in any given factor. Factor analysis was chosen as the scaling method, as opposed to prospective reliability scaling (using Cronbach's alpha or similar techniques), because the survey questionnaire was not originally intended for scale development and examined a divergent array of issues. The factor analyses permitted examination of common themes that would not have been predicted in advance. Second, the factor scores were used as dependent variables and regressed against physician characteristics such as self-reported primary specialty, type of practice (e.g., solo or group -self-employed or salaried), percent of time spent in direct patient care, and membership in the AMA or the state medical society. It would have been desirable to include other personal characteristics, such as age, gender, socioeconomic background, or geographic region, but these were not available in the data base. Nonetheless, in similar analyses of earlier surveys, Colombotos and Kirchner (1986) have reported that practice characteristics, not personal traits, are the primary determinants of physician attitudes toward health care issues.
Physicians and Cost Containment
29
RESULTS COMMON THEMES
The factor analysis reduced responses from the 23 policies to nine factors, which accounted for 59.3 percent of the variance. Appendix B contains the loadings from the factor analysis. The factors, their component questions, and the mean scores (on a scale of 1 very acceptable to 4 not at all acceptable) for each of the questions were:
* Factor 1-Increase patient share of cost. Increase insurance deductibles (mean score 1.9); make patients pay a greater share of bills (2.0); make employees pay part of premiums (1.8). * Factor 2-Place external controls on practice. Require prior approval before nonemergency hospitalization, that is, preadmission review (2.8); pay fixed fees to doctors or hospitals for diagnoses, for instance, diagnosis-related groups (2.9); establish government price controls for doctors' and hospitals' fees (3.6); change antitrust laws to permit third party payers to negotiate cost reductions (2.5); encourage utilization review by third party payers (2.5). * Factor 3-Reduce intensity of care. Require second opinions prior to nonemergency surgery (2.0); encourage care in clinics and offices instead of hospitals (1.4); encourage use of nurse practitioners and other allied health (2.8); encourage home care instead of hospitals or nursing homes for the chronically ill (1.4). * Factor 4- Use prepaid health care. That is, use HMOs (2.9); have patients select a primary care doctor who authorizes all care -gatekeepers (2.6). * Factor 5-Reduce incentives for unnecessary care. Make employees pay part of premiums (1.8); make employees pay taxes on premiums after certain levels (2.7); ease laws that encourage doctors to order procedures to protect themselves from malpractice suits (1.8). * Factor 6-Negotiate cost reductions. Change antitrust laws to permit third party payers to negotiate cost reductions (2.5); use employer coalitions to work together to reduce costs (1.9).
HSR: Halth Services Research 25:1 (April 1990, Part I)
30
Factor 7-Seket efficient providers. -Include only low-cost doctors and hospitals, that is, selective contracting (3.0); provide that patients pay less for using selected providers and more for providers not on plan (PPOs) (2.8). * Factor 8-Encourage healthy behavior. Offer insurance incentives to people with healthy behaviors, such as nonsmokers and seatbelt-users (1.3); give refunds to employees when total health plan costs are below target (1.7). * Factor 9-Restrict expensive technology. Discourage having expensive technology at a hospital if available elsewhere nearby, that is, certificate of need (2.2); limit use of expensive technology for terminal patients (2.3). Table 2 summarizes the factors in order of decreasing mean acceptability (or increasing mean score). The mean factor score is the composite score for the policies in each factor. In general, a 0.1 point difference in mean scores is roughly equivalent to a significant difference at a 95 percent confidence level. The reactions can be categorized into three general levels of acceptability. One factor is relatively accptable to most doctors encouraging healthy behaviors. Five are somewhat accptable to most doctors-reducing the intensity of care, increasing patient cost share, reducing incentives for unnecessary care, negotiating cost reductions, and restricting expensive technology. Three are not very accptable to most doctors-using prepaid health care, placing external controls on *
Table 2: Mean Acceptability Scores among Physicians (by Decreasing Popularity)
Factor Encourage healthy behavior Reduce intensity of care Increase patient cost share Reduce incentives for unnecessary care 6. Negotiate cost reductions 9. Restrict expensive technology 4. Work with prepaid health 8. 3. 1. 5.
Mean
Standard Error
N
1.5* 1.9 1.9 2.1
.03 .03 .03 .03
487 470 479 420
2.2 2.2 2.7
.04 .04 .04
458 472 482
care 441 .03 2. Agree to external controls of 2.8 practice 479 7. Select efficient providers .04 2.9 *1 - very acceptable; 2 - somewhat acceptable; 3 - not very acceptable; 4 not at all acceptable.
Physicians and Cost Containment
31
practice, and selecting efficient providers. Of the specific policies considered, only one fell in the ckarly unacceptable category -government price controls on doctors' and hospitals' fees (mean score 3.6). It is worth remembering that responses were not monolithic; doctors varied substantially in their reactions. Even within any given factor, mean scores for given questions varied. The pattern of differences seemed consistent with the structure of physician attitudes identified in the factor analysis. Despite the recent reductions of physicians' dominance of the medical care system, these findings indicate the continuing importance of professional autonomy to doctors. In general, physicians found most acceptable those policies that shifted costs or responsibilities to patients and least acceptable those policies that required changes in physician behaviors or practice patterns. Roughly in the middle were policies that reduced certain elements of high-cost care, such as reduced intensity of care or restriction of expensive technology. Prepaid health care, external controls of practice, and selection of efficient providers all directly affect the way physicians obtain patients, practice medicine, and get paid for services. While these policies also have economic effects on doctors, it should be remembered that all of the policies considered sought to contain costs and thus might reduce physicians' incomes. For example, increasing patients' costs would reduce the volume of service demanded and, by extension, should decrease physician visits and income. Nonetheless, physicians prefer this to external controls of practice, prepaid health, or selection of efficient providers. It is difficult to differentiate clearly between economic self-interest and autonomy; Starr (1982) has emphasized the historical importance of professional sovereignty in improving the financial status of doctors. Conceptually, it would be interesting to assign ratings of autonomy and income effects to every policy and to test the comparative influence of these factors on physician preference. However, since any policy can be implemented with differing degrees of aggressiveness, such ratings would be somewhat arbitrary. We believe the structure of the factors identified is more consistent with an interpretation of autonomy as a key determinant of physician attitudes. However, there is probably some degree of overlap between autonomy and economic self-interest in the physician ratings. One example might be further used to elucidate the theme of professional autonomy and dominance. In principle, second opinions and preadmission review serve a similar purpose- checking on the appropriateness of a nonemergency hospitalization through external review. However, preadmission review was grouped in a different fac-
32
HSR: Health Services Research 25:1 (April 1990, Part I)
tor than second opinions and was much less acceptable (mean score of 2.8 versus 2.0). Doctors seem to think of preadmission review, usually conducted by a nurse who does not examine the patient, as an external constraint on their practice, while second opinion, usually conducted by a physician in the same specialty, is more collegial in nature. Others have noted that physicians prefer review processes that are more collegial and informal than those based on explicit protocols (Colombotos and Kirchner 1986). Whether utilization review is resented because nurses do it or because it is not collegial, physicians seem to prefer greater control of the process. DIFFERENCES AMONG PHYSICIANS
The second phase of the analysis asked whether there were different attitudes among different kinds of doctors, using multiple regression. In initial analyses, we explored differences between primary care physicians (family and general practitioners, pediatricians, and obstetricians/gynecologists combined) and specialists (all others). We failed to detect any significant differences between primary care and specialty doctors, thus defined. The physicians were disaggregated into specialties, as shown in Table 1, to test for finer specialty differences. As with much attitudinal research, the sample characteristics explained a relatively small share of the sample variance, that is, less than 15 percent at best. In fact, of the nine factors examined, six did not yield overall model significance less than .05. For all intents and purposes, no significant differences were found among physicians in their reactions to placing external controls of practice, reductions in intensity of care, reductions in incentives for unnecessary care, selection of efficient providers, encouragement of healthy behaviors, and restrictions on expensive technology. There were significant differences among the sample respondents for three factors: increasing patients' cost share, using prepaid health care, and negotiating cost reductions. The results for these three regressions are shown in Table 3. To analyze categorical data, one group, designated as the reference group, is excluded from analysis. It is helpful to choose a reference group that is extreme in values and large enough to yield stable estimates. Surgeons were the reference group for specialties, and solo physicians were used as the reference group for practice type. Both groups had relatively conservative attitudes and relatively large sample sizes. For increasing patients' cost share, psychiatrists, pediatricians, and other medical specialists had significantly higher scores than sur-
Physicians and Cost Containment
33
Table 3: Multiple Regression Results for Significant Models (p
In a booklet called Physician's Cost Containment Checklist, the American Medical Association (AMA) (1985) has described this current period as one of "turbulent times for the medical profession." In order to contain inflation in health care costs, for over a decade insurers, businesses, and government have sought to make health care more efficient and to change the way doctors practice medicine. Buffeted by powerful economic and social forces, American physicians are losing their tradiThis work was supported in part by a grant from the Pew Memorial Trust. Address correspondence and requests for reprints to Leighton Ku, Systemetrics/ McGraw-Hill, 24 Hartwell Avenue, Lexington, MA 02173. Dena Fisher is with Continuing Care Consulting, Goldens Bridge, NY. This work was conducted when the authors were Pew Health Policy Fellows at the Health Policy Institute, Boston University and the Heller School, Brandeis University, respectively.
26
HSR: Health Services Research 25:1 (April 1990, Part I)
tional sovereignty and dominance of the medical care system (Starr 1982; Freidson 1970; McKinlay and Stoeckle 1988; Colombotos and Kirchner 1986). Physicians, who once spoke with unquestioned authority, now find their decisions challenged by administrators. Further signs of metamorphosis are the decreases in solo fee-for-service practice as doctors increasingly join group practices, health maintenance organizations (HMOs), independent practice associations (IPAs), and preferred provider organizations (PPOs). Anecdotal reports state that "doctors are in a state of fear" (Hanna 1988) and that they are asking whether it is still a privilege to be a doctor (New England Journal of Medicine 1986), but there are almost no surveys of physician attitudes available in the published literature. This article seeks to examine physician attitudes to 23 costcontainment measures, based on a 1984 survey conducted by Louis Harris and Associates for the Equitable Life Assurance Society of the United States (now Equicor) (1983, 1984). The analyses seek to answer:
* What policies are favored and disfavored by physicians? More important, what are the common themes underlying their attitudes? * What practice characteristics are associated with differing attitudes? For example, do primary care physicians differ from specialists or solo doctors from group practice doctors? We discuss these findings in the context of how physicians' attitudes develop and change over time. Finally, we examine how these attitudes may interact with the interests of the public and payers in shaping health care policy.
METHODOLOGY The Equitable Healthcare Survey II: Physicians'Attitudes Toward Cost Containment (1984) was based on a national telephone survey of 500 practicing physicians conducted in January and February 1984. The sampling frame was derived from an AMA master file, which included both AMA members and nonmembers. To attain a final sample of 500, 2,500 physicians were randomly selected and clustered by region in groups of five names. If the first person could not be contacted or would not participate, the interviewer contacted another from the cluster until a respondent was found. Louis Harris and Associates report a response rate of 55 percent, which is within the normal range for phone
Physicians and Cost Containment
27
surveys of physicians (Taylor 1989). Respondents received a token payment in compensation for their time, among other efforts made to reduce nonresponse. Table 1 describes the sample of physicians. Although the overall sample of physicians is nationally representative, the number of physicians in any particular group, such as surgeons or HMO doctors, is relatively small. Thus, findings about a given specialty may not be generalizable to the nation.
Table 1: Description of the Physicians in the Sample (N= 500) Characteristic Primary Specialty Family practice General practice Internal medicine Obstetrics/Gynecology Pediatrics Anesthesiology Radiology/Pathology Psychiatry Other medical specialties Surgery, all types Other Primary type of practice Solo or expense-sharer Group self-employed Group salaried Hospital staff HMO staff Other Not stated American Medical Association Member Nonmember Not stated State Medical Society Member Nonmember Not stated Percent of time spent in direct patient care
Number
Percent
66 18 61 48 34 27 56 43 76 58 13
13.2 3.6 12.2 9.6 6.8 5.4 11.2 8.6 15.2 11.6 2.6
217 131 56 46 13 32 5
43.4 26.2 11.2 9.2 2.6 6.4 1.0
266 232 2
53.2 46.4 .4
401 97 2 Mean 79
80.2 19.4 .4 Standard Deviation 19
28
HSR: Health Services Research 25:1 (April 1990, Part I)
The overall survey examined issues regarding health care cost containment and the U.S. medical care system, including perceived reasons for health care cost inflation, priorities for change in the system, and the like. It paralleled a prior Equitable/Louis Harris survey of the public, business executives, insurers, and others of issues regarding the American health care system (The Equitable Life Assurance Society of the United States 1983). Of particular interest in this analysis were questions about the acceptability of 23 policies (which will be discussed in more detail later) that were coded as: 1.- very acceptable, 2- somewhat acceptable, 3- not very acceptable, and 4- not at all acceptable. Appendix A states the wording of the questions analyzed in this article. The 23 policy options were based on Equitable's perceptions of the dominant health care cost-containment options under discussion in 1984. A list drawn today would be quite similar. The analysis in this article has two major parts. First, factor analysis was used to summarize the information regarding the 23 policies and to identify the common themes in the responses. Principal components factor analysis and varimax rotation were used. A variety of models were examined; the final models were selected on their technical merits, such as percent of variance explained, and on the intuitive sensibility of the factors. After the factors were derived, factor scores were computed as the mean of the variable scores that had factor loadings greater than 0.4. Thus, they are composite scores for the factors most influential in any given factor. Factor analysis was chosen as the scaling method, as opposed to prospective reliability scaling (using Cronbach's alpha or similar techniques), because the survey questionnaire was not originally intended for scale development and examined a divergent array of issues. The factor analyses permitted examination of common themes that would not have been predicted in advance. Second, the factor scores were used as dependent variables and regressed against physician characteristics such as self-reported primary specialty, type of practice (e.g., solo or group -self-employed or salaried), percent of time spent in direct patient care, and membership in the AMA or the state medical society. It would have been desirable to include other personal characteristics, such as age, gender, socioeconomic background, or geographic region, but these were not available in the data base. Nonetheless, in similar analyses of earlier surveys, Colombotos and Kirchner (1986) have reported that practice characteristics, not personal traits, are the primary determinants of physician attitudes toward health care issues.
Physicians and Cost Containment
29
RESULTS COMMON THEMES
The factor analysis reduced responses from the 23 policies to nine factors, which accounted for 59.3 percent of the variance. Appendix B contains the loadings from the factor analysis. The factors, their component questions, and the mean scores (on a scale of 1 very acceptable to 4 not at all acceptable) for each of the questions were:
* Factor 1-Increase patient share of cost. Increase insurance deductibles (mean score 1.9); make patients pay a greater share of bills (2.0); make employees pay part of premiums (1.8). * Factor 2-Place external controls on practice. Require prior approval before nonemergency hospitalization, that is, preadmission review (2.8); pay fixed fees to doctors or hospitals for diagnoses, for instance, diagnosis-related groups (2.9); establish government price controls for doctors' and hospitals' fees (3.6); change antitrust laws to permit third party payers to negotiate cost reductions (2.5); encourage utilization review by third party payers (2.5). * Factor 3-Reduce intensity of care. Require second opinions prior to nonemergency surgery (2.0); encourage care in clinics and offices instead of hospitals (1.4); encourage use of nurse practitioners and other allied health (2.8); encourage home care instead of hospitals or nursing homes for the chronically ill (1.4). * Factor 4- Use prepaid health care. That is, use HMOs (2.9); have patients select a primary care doctor who authorizes all care -gatekeepers (2.6). * Factor 5-Reduce incentives for unnecessary care. Make employees pay part of premiums (1.8); make employees pay taxes on premiums after certain levels (2.7); ease laws that encourage doctors to order procedures to protect themselves from malpractice suits (1.8). * Factor 6-Negotiate cost reductions. Change antitrust laws to permit third party payers to negotiate cost reductions (2.5); use employer coalitions to work together to reduce costs (1.9).
HSR: Halth Services Research 25:1 (April 1990, Part I)
30
Factor 7-Seket efficient providers. -Include only low-cost doctors and hospitals, that is, selective contracting (3.0); provide that patients pay less for using selected providers and more for providers not on plan (PPOs) (2.8). * Factor 8-Encourage healthy behavior. Offer insurance incentives to people with healthy behaviors, such as nonsmokers and seatbelt-users (1.3); give refunds to employees when total health plan costs are below target (1.7). * Factor 9-Restrict expensive technology. Discourage having expensive technology at a hospital if available elsewhere nearby, that is, certificate of need (2.2); limit use of expensive technology for terminal patients (2.3). Table 2 summarizes the factors in order of decreasing mean acceptability (or increasing mean score). The mean factor score is the composite score for the policies in each factor. In general, a 0.1 point difference in mean scores is roughly equivalent to a significant difference at a 95 percent confidence level. The reactions can be categorized into three general levels of acceptability. One factor is relatively accptable to most doctors encouraging healthy behaviors. Five are somewhat accptable to most doctors-reducing the intensity of care, increasing patient cost share, reducing incentives for unnecessary care, negotiating cost reductions, and restricting expensive technology. Three are not very accptable to most doctors-using prepaid health care, placing external controls on *
Table 2: Mean Acceptability Scores among Physicians (by Decreasing Popularity)
Factor Encourage healthy behavior Reduce intensity of care Increase patient cost share Reduce incentives for unnecessary care 6. Negotiate cost reductions 9. Restrict expensive technology 4. Work with prepaid health 8. 3. 1. 5.
Mean
Standard Error
N
1.5* 1.9 1.9 2.1
.03 .03 .03 .03
487 470 479 420
2.2 2.2 2.7
.04 .04 .04
458 472 482
care 441 .03 2. Agree to external controls of 2.8 practice 479 7. Select efficient providers .04 2.9 *1 - very acceptable; 2 - somewhat acceptable; 3 - not very acceptable; 4 not at all acceptable.
Physicians and Cost Containment
31
practice, and selecting efficient providers. Of the specific policies considered, only one fell in the ckarly unacceptable category -government price controls on doctors' and hospitals' fees (mean score 3.6). It is worth remembering that responses were not monolithic; doctors varied substantially in their reactions. Even within any given factor, mean scores for given questions varied. The pattern of differences seemed consistent with the structure of physician attitudes identified in the factor analysis. Despite the recent reductions of physicians' dominance of the medical care system, these findings indicate the continuing importance of professional autonomy to doctors. In general, physicians found most acceptable those policies that shifted costs or responsibilities to patients and least acceptable those policies that required changes in physician behaviors or practice patterns. Roughly in the middle were policies that reduced certain elements of high-cost care, such as reduced intensity of care or restriction of expensive technology. Prepaid health care, external controls of practice, and selection of efficient providers all directly affect the way physicians obtain patients, practice medicine, and get paid for services. While these policies also have economic effects on doctors, it should be remembered that all of the policies considered sought to contain costs and thus might reduce physicians' incomes. For example, increasing patients' costs would reduce the volume of service demanded and, by extension, should decrease physician visits and income. Nonetheless, physicians prefer this to external controls of practice, prepaid health, or selection of efficient providers. It is difficult to differentiate clearly between economic self-interest and autonomy; Starr (1982) has emphasized the historical importance of professional sovereignty in improving the financial status of doctors. Conceptually, it would be interesting to assign ratings of autonomy and income effects to every policy and to test the comparative influence of these factors on physician preference. However, since any policy can be implemented with differing degrees of aggressiveness, such ratings would be somewhat arbitrary. We believe the structure of the factors identified is more consistent with an interpretation of autonomy as a key determinant of physician attitudes. However, there is probably some degree of overlap between autonomy and economic self-interest in the physician ratings. One example might be further used to elucidate the theme of professional autonomy and dominance. In principle, second opinions and preadmission review serve a similar purpose- checking on the appropriateness of a nonemergency hospitalization through external review. However, preadmission review was grouped in a different fac-
32
HSR: Health Services Research 25:1 (April 1990, Part I)
tor than second opinions and was much less acceptable (mean score of 2.8 versus 2.0). Doctors seem to think of preadmission review, usually conducted by a nurse who does not examine the patient, as an external constraint on their practice, while second opinion, usually conducted by a physician in the same specialty, is more collegial in nature. Others have noted that physicians prefer review processes that are more collegial and informal than those based on explicit protocols (Colombotos and Kirchner 1986). Whether utilization review is resented because nurses do it or because it is not collegial, physicians seem to prefer greater control of the process. DIFFERENCES AMONG PHYSICIANS
The second phase of the analysis asked whether there were different attitudes among different kinds of doctors, using multiple regression. In initial analyses, we explored differences between primary care physicians (family and general practitioners, pediatricians, and obstetricians/gynecologists combined) and specialists (all others). We failed to detect any significant differences between primary care and specialty doctors, thus defined. The physicians were disaggregated into specialties, as shown in Table 1, to test for finer specialty differences. As with much attitudinal research, the sample characteristics explained a relatively small share of the sample variance, that is, less than 15 percent at best. In fact, of the nine factors examined, six did not yield overall model significance less than .05. For all intents and purposes, no significant differences were found among physicians in their reactions to placing external controls of practice, reductions in intensity of care, reductions in incentives for unnecessary care, selection of efficient providers, encouragement of healthy behaviors, and restrictions on expensive technology. There were significant differences among the sample respondents for three factors: increasing patients' cost share, using prepaid health care, and negotiating cost reductions. The results for these three regressions are shown in Table 3. To analyze categorical data, one group, designated as the reference group, is excluded from analysis. It is helpful to choose a reference group that is extreme in values and large enough to yield stable estimates. Surgeons were the reference group for specialties, and solo physicians were used as the reference group for practice type. Both groups had relatively conservative attitudes and relatively large sample sizes. For increasing patients' cost share, psychiatrists, pediatricians, and other medical specialists had significantly higher scores than sur-
Physicians and Cost Containment
33
Table 3: Multiple Regression Results for Significant Models (p
