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Global Payment Contract Attitudes and Comprehension Among Internal Medicine Physicians
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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.
DISCUSSION
Four years since first engaging in a GPC, a majority of Department of Medicine physician survey respondents within our care organization were supportive of this decision. We identified several physician attributes independently associated with GPC support, including greater knowledge of GPCs. To our knowledge, our study represents the first published survey of academic physician attitudes on this topic.
 
Prior industry surveys and analyses have identified physicians as potential barriers to implementation of organizational reform.5,7 In contrast, our study of academic internists demonstrates notable support for a model that requires significant change on an organizational level. This could be partially due to the presence of financial and nonfinancial incentives in academic medical centers that can insulate practitioners from market forces.13,14 While this has previously been depicted as a challenge, based on our results we propose that it may also serve as a strength in facilitating organizational change.15 Salaried physicians with academic appointments may worry less about risk-sharing agreements, as a majority of the immediate risk is carried by the physician organization or hospital. As a result, academic physicians may be more open to the idea of organizational restructuring required by GPCs, as well as issues such as cost control and quality of care (cited by 69.8% and 47.1% of respondents in support of GPC involvement). The degree to which our findings are generalizable to nonacademic settings with productivity-based compensation should be investigated.
 
Despite public views of physicians as being focused on financial concerns, physicians in our survey infrequently cited (11.3%) personal monetary benefit as playing a role in their decision to support or oppose involvement in a GPC.16,17 Furthermore, despite documented “wage gaps” between generalist and specialist physicians, there was no association between generalist versus specialist status and GPC support.18
 
Understanding predictors of internist support for GPCs within our care organization may help other academic health systems approach organizational change. We found that demonstrated knowledge about GPCs and a history of educational exposure to GPCs, regardless of format, was associated with an increased likelihood of supporting involvement in GPCs. These findings suggest that physician education efforts, whether formal or informal, may be effective tools for shaping physician opinion on an organizational level.
 
The likelihood of supporting GPCs was positively associated with increased time since completion of residency and decreased clinical time commitment. We hypothesize that older academic internists and those who spend less time working in clinical activities may be more involved in administrative positions that allow them a better understanding of the organizational issues that motivate GPC involvement.
 
Limitations
Our study has several limitations. While our study sample was large enough to allow for identification of associations within our organization, the single-center nature of our study may limit generalizations beyond our organization. In particular, the academic nature and high proportion of salaried physicians within the Department of Medicine limits generalizability to settings with a higher proportion of nonsalaried physicians, where GPCs may have greater financial ramifications for individual physicians. Additionally, although physician beliefs regarding certain recent health reform efforts were similar across regions, support for GPCs may depend on geography and local political leanings.19,20 Within our organization, located in urban Massachusetts, political support for health reform was a frequently cited reason for support of GPCs. Although our survey was sent by study authors and not departmental or care organization leadership, and participants were informed that responses were anonymous, participants may have overestimated their support for GPC involvement due to perceived organizational norms. Additionally, it is possible that survey respondents differed from nonrespondents in ways that could have affected the results. Regarding our attempt to identify potentially modifiable predictors of opinion, the cross-sectional nature of our investigation limits our ability to demonstrate causation. While we found that physicians with exposure to informational sources on GPCs are most likely to support GPCs, it may be that physicians who support GPCs are more likely to seek out informational sessions. Additionally, despite our use of focus groups as part of the survey design process, it is possible that our questions were not interpreted as intended, or were interpreted differently between respondents. As we did not survey physicians in other departments, we are unable to draw conclusions about physicians outside the Department of Medicine.
 
CONCLUSIONS
In conclusion, in a survey of internal medicine physicians within an organization with more than 4 years of experience with GPCs, there was overwhelming support for this involvement. Greater knowledge regarding GPCs and exposure to informational sources about GPCs correlated with higher levels of support for GPC involvement. These findings suggest potential targets for increasing physician support for GPC involvement.


Acknowledgments
The authors would like to acknowledge the leadership of the Beth Israel Deaconess Medical Center Department of Medicine for their support. The statements contained in this document are solely those of the authors. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

Author Affiliations: Beth Israel Deaconess Medical Center (JA-D, SJH), Boston, MA; University of California – Los Angeles (RK), Los Angeles, CA.

Source of Funding: Dr Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The funding organization had no involvement in any aspect of the study, including design, conduct, and reporting of the study.

Author Disclosures: None of the authors report a relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JA-D, SJH, RK); acquisition of data (JA-D, RK); analysis and interpretation of data (JA-D, SJH, RK); drafting of the manuscript (JA-D, RK); critical revision of the manuscript for important intellectual content (JA-D, SJH, RK); statistical analysis (JA-D, SJH); administrative, technical, or logistic support (JA-D); and supervision (JA-D, RK).

Address correspondence to: Joshua Allen-Dicker, MD, MPH, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Hospital Medicine, W/Span-2, Boston, MA 02215. E-mail: DrJoshuaAD@gmail.com.
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