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We present a model of hypothesized relationships between physician satisfaction, physician well-being and the quality of care, in addition to a review of relevant literature. The model suggests that physicians who are stressed, burned out, depressed, and/or have poor self-care are more likely to be dissatisfied, and vice-versa. Both poor physician well-being and physician dissatisfaction are hypothesized to lead to diminished physician concentration, effort, empathy, and professionalism. This results in misdiagnoses and other medical errors, a higher rate of inappropriate referrals and prescriptions, lower patient satisfaction and adherence to physician recommendations, and worse physician performance in areas not observed by others. Research to date largely supports the model, but high quality studies are few. Research should include studies that are prospective, larger, and have a stronger analytic design, ideally including difference in differences analyses comparing quality of care for patients of physicians who become dissatisfied to those who remain satisfied, and vice versa.
Keywords: physician satisfaction, physician dissatisfaction, quality of care, physician well-being, physician burnout

This paper addresses several root causes of dissatisfaction with medical practice among American physicians, and suggests that some, but not all, are potentially remediable. Fixed assumptions about the nature of medical practice in the United States, developed over several decades, appear to be eroding. At the same time, increasing demands on physician time, especially involving low value documentation and administrative tasks are interfering with the physician-patient interaction. In addition, physician practice structure and payment methodologies are beginning to change in the United States leading to a sense of practice instability among physicians. Recent research conducted by the American Medical Association and the RAND Corporation has provided new qualitative and quantitative information about the impact of these trends on physician practices. An evaluation of these research findings indicates that some improvements in physician satisfaction are possible. Keywords: physician professionalism, practice satisfaction, electronic health records, health care reform in the U.S.

A key component of efforts to improve the quality of care in the United States is the use of public reporting and pay-for-performance programs. Little is known, however, about the extent to which small- and medium-sized physician practices are participating in these programs. This study examined the participation of small- and medium-sized physician practices in pay-for-performance and public reporting programs and the characteristics of the participating practices. Using cross-sectional data from a national sample of 1,734 small- and medium-sized physician practices throughout the United States, we found that many practices (61.2%) were participating in at least one program, while far fewer (19.2%) were participating in multiple programs. Among practices participating in multiple programs, relatively few (21.9%) reported high levels of administrative problems due to a lack of standardization on performance measures. The study also suggests that some structural features are associated with participation and may provide leverage points for fostering participation.

The macroeconomic environment has been shown to affect health-care service utilization. We examined the relationship between unemployment rate and service intensity among a nationally representative sample of primary care office visits from Medicare patients by merging data from the 2006–2012 National Ambulatory Medical Care Survey with unemployment data from the Bureau of Labor Statistics. Multispecialty practices demonstrated increases in the number of electrocardiogram tests prescribed and the number of return appointments scheduled. In contrast, single-specialty practices did not respond on those margins and instead increased the likelihood of administering diagnostic and screening examinations. We found no significant relationship between unemployment rates and the number of laboratory and imaging services, magnetic resonance imaging use, referrals, or medication prescribing. These results were robust to controlling for extensive visit characteristics and county-, year-, and month-fixed effects. Our results suggest that physicians responded to the Great Recession by changing their practice behavior.

Pay-for-performance and public reporting programs may have a neutral, narrowing, or widening effect on racial disparities in health care. The authors begin this article by suggesting that certain characteristics of these programs may affect disparities. They then present results from a systematic review of the literature on the effects of performance incentive programs on racial disparities in health care. The review revealed that only one empirical study provided data on this issue: It showed that a major public reporting program increased disparities in coronary artery bypass graft rates. The authors then present the results of interviews with leaders of 15 major performance incentive programs in the United States. The interviews indicated that current programs are not designed to reduce disparities and often lack characteristics that may be important in reducing disparities. The article concludes with program leaders' recommendations on how performance incentive programs could be designed to reduce disparities.

Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

Practice ownership and Medicaid revenue may affect the use of care management processes (CMPs) for chronic conditions and expansion of health information technology (HIT). Using a national cohort of medical practices, we compared the use of CMPs and HIT from 2006/2008 to 2013 by practice ownership and level of Medicaid revenue. Poisson regression models estimated changes in CMP use, and linear regression estimated changes in HIT, by practice ownership and Medicaid patient revenue, controlling for other practice characteristics. Compared with physician-owned practices, system-owned practices adopted a greater number of CMPs and HIT functions over time ( p < .001). High Medicaid revenue (≥30.0%) was associated with less adoption of CMPs ( p < .001) and HIT ( p < .01). System-owned practices ( p < .001) and community health centers ( p < .001) with high Medicaid revenue were more likely than physician-owned practices with high Medicaid revenue to adopt CMPs over time. System and community health center ownership appear to help high Medicaid practices overcome CMP adoption constraints.

IMPORTANCE: It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. EXPOSURE: Nursing home ownership status. MAIN OUTCOMES AND MEASURES: Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. RESULTS: Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, −69.2 to −1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% ...

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations—medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performingmedical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.