Physician commitment to organized delivery systems

BACKGROUND. Health care systems have developed many types of contracting ve hicles with physicians. The immediate aim of these vehicles has been to fos ter physician commitment and alignment to the system. The ultimate aim of t hese vehicles has been to garner managed care contracts, reduce costs, and improve quality, To date, most of these vehicles have failed to improve phy sician commitment. This may be one reason why the ultimate outcomes have no t been observed. Consequently, systems are experimenting with new methods t o partner with physicians. One new method is to segment physicians into tig htly linked and loosely linked strategic alliances and devote different lev els of resources and attention to each. OBJECTIVES. This study evaluates whether the segmentation of physicians int o tightly linked versus loosely linked strategic alliances improves the com mitment of physicians to the system. The study then investigates which cons tituent elements of the tightly linked strategic alliances exhibit the grea test association with commitment. DESIGNS AND SUBJECTS. The study uses a cross-sectional design and survey da ta drawn from 1,965 physicians affiliated with 14 health care systems aroun d the country. Tightly linked physicians typically practiced in hospital-sp onsored group practices, whereas loosely linked physicians typically used t he system's hospitals as their primary site of inpatient practice. MEASURES. Commitment is measured by seven different scales drawn from the l iterature on organizational commitment, loyalty, and identification. Some o f the scales refer to physician attitudes, whereas others describe physicia n behaviors. The literature suggests that commitment is associated with bot h instrumental/utilitarian considerations leg, older age, tenure with syste m, admissions to system, receipt of a stipend, etc.) as well as administrat ive involvement/participation considerations leg, decision-making roles). A series of physician background and practice characteristics are used here to model these two types of factors. RESULTS. The study finds small but significant differences in commitment be tween physicians in tightly linked versus loosely linked alliances. Multiva riate analyses suggest that instrumental/utilitarian factors (eg, age, rece ipt of stipend, percent of admissions to the system) may exhibit stronger a ssociations with commitment than the physician's administrative involvement in the organization. CONCLUSIONS. To the degree that physician commitment is possible, systems s hould appeal to physicians' calculative motivations using extrinsic rewards rather than normative involvement in the organization.