Physician commitment to organized delivery systems

BACKGROUND. Health care systems have developed many types of contracting vehicles with physicians. The immediate aim of these vehicles has been to foster physician commitment and alignment to the system. The ultimate aim of these vehicles has been to garner managed care contracts, reduce costs, and improve quality. To date, most of these vehicles have failed to improve physician commitment. This may be one reason why the ultimate outcomes have not been observed. Consequently, systems are experimenting with new methods to partner with physicians. One new method is to segment physicians into tightly linked and loosely linked strategic alliances and devote different levels of resources and attention to each. OBJECTIVES. This study evaluates whether the segmentation of physicians into tightly linked versus loosely linked strategic alliances improves the commitment of physicians to the system. The study then investigates which constituent elements of the tightly linked strategic alliances exhibit the greatest association with commitment. DESIGNS AND SUBJECTS. The study uses a cross-sectional design and survey data drawn from 1,965 physicians affiliated with 14 health care systems around the country. Tightly linked physicians typically practiced in hospital-sponsored group practices, whereas loosely linked physicians typically used the system's hospitals as their primary site of inpatient practice. MEASURES. Commitment is measured by seven different scales drawn from the literature on organizational commitment, loyalty, and identification. Some of the scales refer to physician attitudes, whereas others describe physician behaviors. The literature suggests that commitment is associated with both instrumental/utilitarian considerations (eg, older age, tenure with system, admissions to system, receipt of a stipend, etc.) as well as administrative involvement/participation considerations (eg, 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 between physicians in tightly linked versus loosely linked alliances. Multivariate analyses suggest that instrumental/utilitarian factors (eg, age, receipt of stipend, percent of admissions to the system) may exhibit stronger associations with commitment than the physician's administrative involvement in the organization. CONCLUSIONS. To the degree that physician commitment is possible, systems should appeal to physicians' calculative motivations using extrinsic rewards rather than normative involvement in the organization.