Risk Assumption and Physician Alignment with Health Care Organizations

Objectives. To examine the association between risk assumption by individual physicians and physician groups and the degree of alignment between physicians and health care systems. Methods. A cross sectional comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians. Measures of risk assumption were developed from surveys sent to the administrator of each of the 61 physician groups in the sample and to physicians affiliated with these groups. Two stage Heckman models with fixed effects adjustments in the second stage were used to correct for sample selection and clustering respectively. Results. After accounting for selection, fixed effects, and group and individual controls, physicians in groups with larger proportional revenue from managed care displayed greater normative commitment and system loyalty than physicians in groups with lower proportional managed care revenue. Individual-level managed care risk was also positively related to both normative commitment and group behavioral commitment to the system. Physicians in groups with larger physician equity positions expressed lower levels of normative commitment to the system. Physician productivity compensation was negatively related to all measures of alignment. Finally, group emphasis on individually-based incentives for staff physicians was negatively related to system identification. Conclusions. Our findings suggest that organizations must balance individually-based risk schemes with those that emphasize the performance of the group and the system to achieve long-term goals of loyalty, identification, and commitment to the system.