The impact of financial constraints and incentives on professional autonomy

Abstract

General practice has been the subject of extensive reforms over the 1990s in Australia as elsewhere. Reforms have attempted to improve quality and contain the overall cost of health care, and have often been seen as reducing the autonomy of medical professionals. This paper examines the impact of financial constraints and incentives introduced during the 1990s on Australian GPs' perceptions of autonomy. An existing seven component definition of autonomy and six themes that emerged from reviewing publications were used to construct focus group questions. A total of 25 GPs participated in four focus groups. Those who participated believe that their financial autonomy has been diminished by policy changes and consumer expectations. They also perceive that their ability to control clinical decisions, which they regard as the most important aspect of professional autonomy, has been reduced along with financial autonomy. Organized medicine in Australia sees financial accountability and clinical decision making as polar opposites, and has continued to argue that fee-for-service payment is the only appropriate method of remuneration, despite increasing evidence that this does not guarantee clinical autonomy. Major changes to the financing of general practice in Australia are required to address the concerns of GPs, governments and patients.

Perceived Complexity of Care, Perceived Autonomy, and Career Satisfaction Among Primary Care Physicians

“…Our study also found considerable overlap among consistent predictors (the ability to obtain high-quality services, the proportion of revenue from managed care, and the perceived complexity of care expected greater than it should be). Previous work found that perceived autonomy was related to financial autonomy, 14 discipline, 22 solo practice, 22 and managed care revenues, 24 perhaps because of the effect of incentives to reduce services. 8 Thus, these outcomes are related but not identical.…”

“…9 -12 One explanation for diminishing satisfaction among PCPs may be a decreasing sense of professional autonomy. 13 PCPs are experiencing a loss of perceived autonomy, 14 possibly because of incentives designed to decrease services and expenses. 8 This decline in the sense of autonomy is greater among PCPs compared with specialists.…”

An Empirical Investigation of Factors Influencing Career Satisfaction of Primary Care Physicians

“…Approximately 39% of the 508 responding PCPs said they would become surgical or diagnostic specialists, whereas approximately 22% said they would not choose medicine as a career. 23 In an attempt to shed some light on the declining level of satisfaction, 24 decreasing sense of professional autonomy, 25 and "feelings of powerlessness" 26 in the complex health care environment within which PCPs operate, 27 Katerndahl et al 28 used Community Tracking Survey data collected during 3 consecutive periods (ie, 1996 -1997, 1998 -1999, and 2000 -2001) to examine the relationships of both perceived autonomy and perceived complexity of care on PCPs career satisfaction. They concluded that there is considerable interaction between perceived complexity of care, perceived autonomy, and career satisfaction of PCPs.…”

The decline in ‘free’ general practitioner care in Australia: reasons and repercussions

“…For example, where the service imposes no out-of-pocket payment on the patient, then the incentive for the doctor to suggest a follow-up visit may be increased. It should be noted however that patients have increasing access to health information on the Internet and that this is changing the relationship between the doctor and patient [13].…”

“…Lewis and Marjoribanks [13] comment on the distinction and divergence of views and interests between the macro level of the profession, represented by organised medicine and the micro level which is represented by individual doctors. They note that it is possible that policies agreed to by the professional bodies can enhance some aspects of the profession but may diminish aspects at the micro level.…”