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Global Payment Contract Attitudes and Comprehension Among Internal Medicine Physicians

Joshua Allen-Dicker, MD, MPH; Shoshana J. Herzig, MD, MPH; and Russell Kerbel, MD, MBA
Four years following engagement by an urban care organization in global payment contracts, a majority of internal medicine physicians there were supportive of this action.
Setting and Subjects
Beth Israel Deaconess Care Organization (BIDCO) is an independent physician and hospital network in Massachusetts. At the time of this survey, it consisted of several hospitals as well as physician organizations accounting for 1700 physician providers. Of these, the Department of Medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts, accounted for over 500 physician providers, the majority of whom were paid a salary not based on productivity.
Since 2009, BIDCO has formed GPCs with multiple payer organizations. Existing global payment partners now include Massachusetts Blue Cross Blue Shield via the Alternative Quality Contract (announced 2011), Tufts Health Plan (2011), CMS via the Pioneer Accountable Care Organization program (2012), and Harvard Pilgrim Health Care (2012). At the time of this survey, approximately 60% of patients cared for by BIDCO providers were covered by a GPC.
Prior to and immediately following GPC adoption, the hospital and care organization held global payment orientation sessions throughout the provider network. These educational sessions included formal presentations at divisionwide faculty meetings, and more informal presentations at local practice-based business meetings. Select primary care physicians were identified as champions responsible for communicating important global contract details to local primary care physician colleagues. At the time of our survey, no complementary structure existed for other physician specialties. As physician salary was determined by individual affiliated employers and not the care organization itself, GPC adoption did not directly alter physician compensation.
Ongoing organizational outreach efforts include regular distribution of data on utilization, cost, and quality, as well as medical management initiatives to assist providers in achieving the highest quality and efficiency in healthcare delivery within the system.
Survey Design
We designed a 3-part anonymous survey instrument (eAppendix A, available at The first section collected demographic information, including time since completion of residency, clinical area of practice, time spent on a clinical service, and sources previously consulted to learn about GPCs.
The second section consisted of 10 questions meant to assess comprehension of key concepts related to GPCs. Question topics included definitions and goals, mechanism for billing, role of budgets, role of quality metrics, and organizational-specific information. Question content was developed in conjunction with organizational leadership to ensure accuracy and appropriateness. Respondents were asked not to consult any outside sources while completing this section.
The third section quantified the agreement with the decision to participate in a GPC. The survey asked physicians to rate their level of agreement with the statement, “I support our physician organization’s decision to enter into global payment systems (eg, Medicare Accountable Care Organization, Blue Cross Blue Shield Alternative Quality Contract),” using a Likert scale (strongly agree, agree, disagree, strongly disagree). Depending on physician response, an additional question soliciting reasons for agreement or disagreement was included. Respondents could select multiple predefined answer choices that were sourced from the ongoing dialogue on GPCs in the lay and academic press. A free-text “other” response was allowed, as was no response.
Prior to formal survey administration, 2 focus groups were held that included a total of 8 internal medicine physicians who would not be included in the survey population. In a roundtable format, the survey was assessed for length and each individual question was assessed for reliability of physician understanding.
Survey Administration
In June 2013, e-mails containing a unique link to our survey were sent to all physicians within the Department of Medicine at Beth Israel Deaconess Medical Center, which includes general medicine and internal medicine subspecialist physicians. Contact information was obtained from administrative rosters. Over the subsequent month, 2 reminder e-mails were sent to physicians who had not already completed the survey. All e-mails originated from study authors and not departmental or care organization leadership. The institution’s Committee on Clinical Investigations certified this research protocol as exempt.
Statistical Analysis
Summary statistics were calculated for all variables. General medicine physicians were defined as those who reported practicing primary care, hospital medicine, or geriatric medicine. Specialist physicians were defined as those who reported practicing any other specialty within internal medicine. Time since residency was dichotomized into less than and greater than or equal to 20 years (the time elapsed since the last attempt at national healthcare reform).12
For the 10 GPC knowledge questions, each respondent was given a score based on the percentage of questions they answered correctly.
We used the Fisher’s exact test to assess the bivariable associations between physician characteristics and level of support for GPC involvement as measured via our 4-category response variable (strongly agree, agree, disagree, strongly disagree). We used a multivariate ordinal logistic regression model to derive factors independently associated with level of support for GPC involvement, where our 4-category response variable (strongly disagree, disagree, agree, strongly agree) was the dependent variable, and all physician characteristics were simultaneously included as independent variables. We chose ordinal regression to make full use of our ordered data, maximizing statistical power. All statistical analyses were performed with the JMP Pro 10 statistical software package (SAS Institute, Cary, North Carolina).

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