Monitoring the unobservable: The regulation of quality of physician services at the organizational and market levels under managed care.

摘要

This dissertation investigated the impact of managed care and physician reimbursement regimes, both on the use of quality assessment instruments by payers and on physician practice patterns under specific vignettes. The analysis estimated both organizational and market effects, drawing on responses to the Community Tracking Study, 1996–97, a survey covering a nationally representative sample of 12,528 physicians. Results on organizational effects, controlling for individual physician characteristics, supported the following hypotheses, anchored in multitask agency theory: (1) a direct relationship prevails between the monitoring of physician performance by payers and the use of cost control mechanisms (logit and ordered logit specifications), and (2) physician practice patterns become more conservative as the physician's association with managed care is strengthened (tobit specification). An HMO or a salaried physician was 1.5–3 times more likely to face quality assessment instruments. A 10% increase in capitation revenue increased the likelihood of being monitored by 14%. I also examined the extent to which these organizational effects were modified by HMO penetration and HMO competition, using Hierarchical Modeling techniques. A 20% increase in either penetration or competition was associated with a 15%–25% increase in the probability of a physician facing quality assessment instruments. Higher HMO penetration, but not competition, was also associated with more conservative practice styles. I conclude that effective private and public policies aimed at service quality ought to be cognizant of these independent regulatory effects of the market on physician services that operate beyond formal organizational characteristics and rules.