According to data released by the Chinese Primary Care Association,(1)
30% of physicians in the practice of direct care of patients
were involved in primary care in 2001, compared to 38.2% in
1990. The annual growth rate for the number of total outpatient
visits in primary care clinics has also dropped from 5.49% in
1998 to 2.32% in 1999, to -3.92% in 2000, especially after implementation
of the National Health Insurance (NHI) program in 1995. The
rate of outpatient visits was expected to have dropped even
further in the first quarter of 2001. For monetary estimation,
the annual growth rate for the total amount of medical claims
for primary care decreased from 9.51% in 1998 to 3.89% in 1999,
to -3.85% in 2000, and to -4.48% in the first quarter of 2001.
As a result, implementation of the NHI has not only expedited
shrinkage of primary care, but has also led to reduced incomes
for primary care physicians.(2,3)
Based on the US experience under managed care, physician dissatisfaction
may lead to increased physician turnover and early retirement,
poorer patient adherence, declining patient satisfaction, decreased
continuity of care for patients, and increased costs to the
medical system.(4-8) Similarly to managed care organizations
as dominant players in US health market, the Bureau of National
Health Insurance, as a monopsonist, exerts its overwhelming
purchasing power to limit physicians' autonomy and judgments
in medical practice. Studies have also identified that physician
dissatisfaction is related to excessive workloads and time pressures,
limited personal time, excessive paperwork, insufficient medical
facilities, isolation due to specialization, a lack of leisure
activities, low incomes, personal limitations in knowledge or
ability, and a lack of professional promotions.(7,9-13) Haas
also concluded that age, gender, income, practice in an urban
setting, and work hours are related to the dissatisfaction of
physicians.(14)
However, most of the factors fostering dissatisfaction described
above are based on US experiences. They cannot fully account
for the dissatisfaction of primary care physicians in Taiwan
due to differences in medical and cultural practices. In addition,
it may be an oversimplification to consider factors related
to physicians' dissatisfaction without reference to the possible
effects of the NHI on primary care. Therefore, it is reasonable
to project that dissatisfaction among primary care physicians
not only may affect the quality of patient care, but also may
influence the supply of primary care physicians in Taiwan. Finding
ways to overcome the dissatisfaction among primary care physicians
has become an imperative issue for policy makers to stop the
rapid shrinkage of primary care in Taiwan. However, few studies
could be found related to primary care in Taiwan and dissatisfaction
among primary care physicians after implementation of the NHI.
Therefore, the purpose of this study was to identify factors
related to dissatisfaction among primary care physicians in
Taiwan under the NHI. Understanding the factors related to dissatisfaction
with the NHI not only can reflect discomfort with changes and
unmet expectations of primary care physicians, but also can
indicate areas for improvement and intervention in primary care.
METHODS
This national survey study was conducted using a structured
questionnaire to assess factors related to dissatisfaction
among primary care physicians under the NHI system.
Study population
Subjects for this study were all primary care physicians in
Taiwan. Sampled physicians were those who had registered as
an active primary care physician with the Department of Health
in 2001. In total, 9336 subjects, including 8846 physicians
in private primary care clinics, and 490 physicians in public
primary care clinics, were surveyed in this study. All human
rights and confidentiality were protected.
Instrument
A structured questionnaire was developed by the research team
through a literature review, a panel discussion, and 5 focus
group interviews. The questionnaire consisted of 3 parts.
The first part was comprised of overall satisfaction questions
related to the NHI. Satisfaction level was measured on a 5-point
Likert scale and ranged from very dissatisfied(1) to very
satisfied.(5) The second part of the questionnaire consisted
of 18 items related to dissatisfaction under the NIH by primary
care physicians including(1) increased number of malpractice
claims,(2) the process of purchasing medical equipment,(3)
lack of leisure time,(4) lack of time for continuing education,(5)
inadequate medical equipment or resources,(6) complexity of
medical claims processes,(7) internal managerial problems
in clinics,(8) excessive working hours,(9) gangster blackmail,(10)
decreased incomes,(11) difficulty with patient referrals,(12)
tax claims,(13) difficulties in finding nurses,(14) instability
of NHI regulations,(15) the separation of dispensing medicine
from medical practice,(16) labor standard laws,(17) standards
for group practice, and(18) lack of supportive systems. Respondents
were asked to answer whether or not they were dissatisfied
with these 18 items.
Finally, demographics such as gender, age, marital status,
certification of specialty, years of medical practice, and
years of practice in primary care were included. Instructions
were provided at the beginning of the questionnaire indicating
that a respondent was to indicate whether or not he/she was
dissatisfied with each item under the NHI. To test for content
validity, 8 experts were invited to examine questions related
to appropriateness, importance, and clarity of each item of
the dissatisfaction questionnaire. The content validity index
(CVI) was used and resulted in a value of greater than 0.8.
Some words or sentences were revised in accordance with the
experts' suggestions.
Data collection processes and analysis
Data were collected from October 2001 to December 2001 from
all eligible primary care physicians. Primary care physicians'
names and address were obtained from the Department of Health
in 2001. A stamped, self-addressed return envelope was mailed
with the questionnaire to all primary care physicians.
Statistical analyses were conducted using the Statistical
Package for the Social Sciences (SPSS 10.0 for Windows, 1997,
SPSS, Chicago, IL). All variables were analyzed using descriptive
measures such as frequency, percentage, mean, and standard
deviation. A logistic regression analysis was employed to
identify the statistically significant factors related to
dissatisfaction among primary care physicians under the NHI.
The independent variables included the 18 above-described
items as well as the demographics of the primary care physicians
such as age, gender, marital status, clinic location, certification
of specialty, years of experience in medical practice, and
years of experience in primary care practice. Marital status
was categorized as married, unmarried, widowed, separated,
and remarried. Clinical location was divided into northern
(Taipei City, Taipei County, Taoyuan County, Ilan County,
and Hsinchu County), central (Miaoli County, Taichung County,
Changhua County, Nantou County, and Yunlin County), southern
(Chiayi County, Tainan County, Kaohsiung County, Kaohsiung
City, and Pingtung County), and eastern (Hualien County and
Taitung County) Taiwan. The dependent variable was determined
based on whether or not a primary care physician was dissatisfied
under the NHI (1 = dissatisfaction, 0 = others). Primary care
physicians who answered "very dissatisfied" and
"dissatisfied" were coded as 1 and those who answered
"very satisfied", "satisfied", and "neither
dissatisfied nor satisfied" were recorded as 0. In the
case of categorically independent variables, dummy variables
were created to model the effects of the different levels
of a qualitative independent variable. All regression coefficients
were considered significant at p<0.05. In addition, a "goodness-of-fit
test" was performed to examine whether or not there was
a difference between the characteristics of participants and
the total primary care physicians population.
RESULTS
In total, 1822 questionnaires were returned after 2 telephone
follow-up calls over a 3-week period which yielded a 19.5%
response rate. The demographic characteristics of the respondents
were similar to those of all physicians who registered as
active primary care physicians at the Department of Health
in 2001 with regard to age, gender, and clinic location (see
Table 1). Respondents' age ranged from 25 to 88 years, with
a mean age of 47.66 years (the mean age of the total population
was 46.65 years) and a standard deviation of 10.50 years (see
Table 2). Not surprisingly, males (94.3%) represented the
majority of primary care physicians in Taiwan (the male percentage
of the total population was 93.18%). With regard to marital
status, the overwhelming majority of respondents (96.3%) were
in the "married" category. Only 6 of 1794 respondents
had remarried. As to clinic location, 40% of respondents were
currently practicing in clinics located in northern Taiwan,
26.3% in central Taiwan, 29.8% in southern Taiwan, and only
3.9% in eastern Taiwan.
Of the sampled physicians, 91.5% had specialist certificates.
The mean years of medical practice were 19.59, and the minimum
and maximum years were 1 and 61, respectively. Years of practice
in primary care ranged between < 1 and 58, with a mean
of 11.65 years and a standard deviation of 10.02 years.
Overall satisfaction level of primary care physicians under
the NHI
Of the total sample, 5.7% (N=101) of respondents were very
dissatisfied with, 22.3% (N=397) were dissatisfied with, 16.5%
(N=294) were satisfied with, and only 1.9% (N=32) were very
satisfied with the current medical environment under the NHI.
In other words, 28% (N=498) of respondents were very dissatisfied
or dissatisfied with the current medical environment. Only
18.4% (N=326) of respondents were satisfied or very satisfied
with the current medical environment. The majority of respondents
(53.6%) rated themselves as "neither dissatisfied nor
satisfied" with the current medical environment.
Items considered unsatisfactory by primary care physicians
The top 5 items which primary care physicians felt the most
dissatisfied with under the NHI were decreased income (59%),
instability in NHI regulations (56.1%), excessive working
hours (52.8%), no leisure time (46.9%), and complicated medical
claims under the NHI (44.3%) (Table 3). On the other hand,
the bottom 5 items which primary care physicians felt least
satisfied with were purchases of medical equipment (10.7%),
gangster blackmail (10.9%), internal management in clinics
(13.9%), inadequate medical equipment (14.2%), and difficulties
in transferring or referring patients (14.2%).
Logistic analysis
The logistic regression analysis revealed that the dissatisfaction
level of primary care physicians was significantly positively
related to age (OR=1.029; 95% CI 1.002-1.058; p<0.05) and
dissatisfaction with the items of the number of malpractice
claims (OR=1.744; 95% CI 1.307-2.326; p<0.001), medical
claims under the NHI (OR=1.454; 95% CI 1.128-1.876; p<0.01),
excessive work hours (OR=1.790; 95% CI 1.327-2.413; p<0.001),
decreased incomes (OR=2.812; 95% CI 2.150-3.679; p<0.001),
difficulties in finding nurses (OR=1.379; 95% CI 1.019-1.867;
p<0.05), and the separation of dispensing medicine from
medical practice (OR=1.389; 95% CI 1.051-1.835; p<0.05)
(see Table 4). As a result, primary care physicians who were
older and unhappy about the increased number of malpractice
claims, complicated medical claims under the NHI, excessive
working hours, decreased income, difficulty in finding nurses,
and the separation of dispensing medicine from medical practice
were more likely to be dissatisfied under the NHI.
However, paradoxically, the level of dissatisfaction of primary
care physicians was significantly negatively related to dissatisfaction
with tax claims (OR=0.681; 95% CI 0.514-0.901; p<0.01).
This result may suggest that primary care physicians who were
dissatisfied with tax claims tended to be more satisfied under
the NHI. Variables including gender, marital status, clinic
location, years of medical practice, and years of practice
in primary care were not significantly related to the level
of dissatisfaction of primary care physicians under the NHI.
DISCUSSION
The response rate was only 19.5% in this study even though
the research team expended much effort to increase the result.
The response rate was still low, but it was similar to that
of Lin and Chiang's study,(15) which surveyed 7500 physicians
and yielded only a 21.6% response rate. It could be concluded
that the response rate is reasonable for a national survey
study. However, although the respondents were similar to those
of physicians who registered as active primary care physicians
at the Department of Health in 2001 with regard to age, gender,
and clinic location, other demographic characteristics such
as income and specialty of the respondents and population
were not available in this study. Therefore, there is no means
to demonstrate that the respondents were similar to the entire
population regarding all demographic characteristics, so the
findings of this study should be used very conservatively
to generalize to the entire population.
The findings indicate that age, increased malpractice claims,
increasingly complicated medical claims, excessive working
hours, decreased income, tax claims, difficulties in finding
nurses, and the separation of dispensing medicine from medical
practice were important factors identified with which primary
care physicians were dissatisfied under the NHI.
The results also indicate that age is related to the dissatisfaction
of primary care physicians under the current medical environment
of the NHI. However, this finding was inconsistent with several
previous findings concerning the relationships between physicians'
satisfaction and age.(14,16,17) Previous studies showed that
younger physicians had a greater tendency to be dissatisfied.
The differences may be due to the fact that those studies
were conducted in the US, and there are differences in the
medical culture and practice between the US and Taiwan health
care systems. In addition, the target populations in those
preceding studies were focused on hospital-based physicians
or physicians under managed care rather than primary care
physicians. Therefore, findings based on the US experience
might not fully explain the relationship between age and dissatisfaction
of primary care physicians under the NHI in Taiwan.
A possible reason contributing to the positive relationship
between age and dissatisfaction among primary care physicians
in Taiwan could be the erosion of professional sovereignty.
Most older primary care physicians experienced the "golden
years" of primary care in Taiwan between 1970 and 1990.(2)
During this period of time, the medical profession was the
highest-paid occupation in society and exercised dominant
control over health markets and medical organizations. Moreover,
the profession turned its authority into social privilege,
economic power, and political influence. The medical profession
thus had an influential claim to authority. However, after
implementation of the NHI system in 1995, most physicians
were paid by whatever services they provided under the BNHI
instead of by traditional out-of-pocket payments from patients.
The physicians' authority in medicine has been threatened
and challenged by the BNHI, which now controls the amount
and rate of remuneration for physicians and the allocation
of medical resources. Colby in 1997 stated that the loss of
autonomy to corporations owned by others was probably the
greatest fear of physicians.(18) Stoddard and his colleagues
in 2001 also indicated that professional autonomy was a strong
independent predictor of physician satisfaction.(19) Loss
of control over clinical and related matters is reflected
in physicians' dissatisfaction with the current health environment
under the NHI.
Traditionally, primary care physicians would stay in their
own clinics as long as possible to avoid losing any potential
patients. Lin in 1999 concluded that the average primary care
physician in Taiwan works 9.36 hours per day and 6.20 days
per week.(2) The long working hours led to a shortage of time
for primary care physicians to attend continuing education
programs. Moreover, according to a study by Mawardi, physicians
may be dissatisfied with their limited medical knowledge or
abilities,(11) since the pace of growth in medical technology
was faster than expected during the past 2 decades. Thus,
primary care physicians in Taiwan have to absorb updated medical
knowledge to stay competitive with hospital-based physicians
in the healthcare market. In particular, the increasingly
complicated procedures of medical claims under the NHI require
physicians to receive continuing education so they can remain
competent. However, the lack of time for continuing education
was not significantly related to the level of dissatisfaction
under the NHI in this study. Further investigation is needed
in the future to understand the relationship between continuing
education and dissatisfaction.
In this study, as many as 46.9% of respondents expressed dissatisfaction
with their lack of leisure time. However, no statistically
significant relationship was found between dissatisfaction
of primary care physicians and dissatisfaction with the lack
of leisure time in this study. This is inconsistent with the
conclusion by Lee and Chou in 1991 who found that the lack
of leisure time was an important factor related to the dissatisfaction
of primary care physicians.(12)
Not surprisingly, this study revealed that dissatisfaction
with decreased income was one of the most important factors
predicting dissatisfaction among primary care physicians under
the NHI. We found that 59% of respondents were dissatisfied
with their decreased income. This finding is supported by
2 related studies.(12,16) The decreased income can be partly
attributed to a reduction in the number of total outpatient
visits for primary care clinics. For example, the growth rate
in the number of total outpatient visits for primary care
clinics was -3.91% in 2000, in contrast to a 4.16% gain for
medical centers and a 2.84% gain for regional hospitals. Similarly,
the growth rate of the total monetary amount of medical claims
for primary care clinics was -3.94% in 2000, in contrast to
a 5.82% gain for medical centers and a 2.53% gain for regional
hospitals. Both of these contributed to the drop in physicians'
incomes.
This study also found that dissatisfaction with increased
medical malpractice claims was related to dissatisfaction
among primary care physicians under the NHI. According to
data released by the Department of Health, Taiwan, in 2000,
the number of malpractice lawsuits increased 58.5% after the
inception of the NHI in 1995. A possible explanation for the
increase in the number of malpractice lawsuits is that people
have progressively recognized the importance of protecting
their own rights when facing an imbalanced relationship in
medical knowledge with physicians. As a result of the widespread
use of Web sites to search for medical knowledge, public trust
in physicians has decreased accompanied by an increase in
the number of malpractice lawsuits. Some other studies have
also documented that malpractice lawsuits were related to
physician dissatisfaction.(11,20)
Aside from the decreased trust in physicians, another possible
explanation for the increase in the number of malpractice
lawsuits is that primary care physicians do not practice much
defensive medicine since the BNHI does not reimburse for that.
Shi and Singh defined defensive medicine as excessive medical
tests and procedures performed as a protection against malpractice
lawsuits.(21) Further research is needed to explore the effects
of increased medical malpractice claims on changes in physician
behavior and incomes in Taiwan.
Physician dissatisfaction with the complicated procedures
for medical claims under the NHI also had a statistically
significant relationship with dissatisfaction among primary
care physicians; 44.3% of respondents were dissatisfied with
medical claims in the study. This reflects physician dissatisfaction
with the increased administrative burden and unstable regulations
under the NHI. One recent study of Stoddard and his colleagues
in 2001 also indicated that physicians consider external regulations
and paperwork as problems in medical practice.(19)
Exploring the factors related to dissatisfaction of primary
care physicians not only can help policy makers understand
differences between reality and expectations, but can also
identify areas for improvement and intervention. In particular,
almost 1/3 of primary care physicians were reportedly dissatisfied
with the current medical environment under the NHI. Primary
care physician dissatisfaction may lead to increased physician
turnover and early retirement which will contribute to the
continued shrinkage of primary care. Therefore, in order to
stop the continued erosion of primary care services, the Department
of Health or the BNHI should encourage primary care physicians
to join a group practice, which is characterized as the provision
of health care services by 2 or more physicians who are formally
organized as a legal entity. Particularly, primary care physicians
have long working hours and are overloaded with paperwork
in a solo practice. A group practice setting can provide primary
care physicians with more leisure time, greater access to
capital, more regular working hours, more time for continuing
education, and more opportunities to employ a full-time person
to deal with medical claims under the NHI compared to solo
primary care practitioners. Moreover, further research is
needed to include the possible effects of the implementation
of a policy for a reasonable number of outpatients and a global
budget system on dissatisfaction among primary care physicians.
Limitations
Because the data were obtained from a self-reporting survey
by primary care physicians throughout Taiwan, some data may
have been over- or under-reported. The extent of over-reporting
and under-reporting was difficult to estimate, but could have
resulted in overestimation or underestimation of the level
of satisfaction of primary care physicians under the NHI.
Additionally, as this study may be the first national survey
study concerning dissatisfaction among primary care physicians
under the NHI, comparison with other studies is not possible.
Therefore, further study is needed to understand whether or
not these primary care physicians' reports are valid.
Since this study was a cross-sectional national survey, it
is difficult to understand the relationship between causes
and effects of the dissatisfaction of primary care physicians.
Therefore, a longitudinal study is also needed to clarify
this relationship in the future. Additionally, the low response
rate may be a natural limitation of a national survey study;
thus, the findings of this study should be used very conservatively
to generalize to the entire population.
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