Influences on Physicians’ Participation in Coordinated Ambulatory Cardiology Care: A Mixed-Methods Study

Patrick Hennrich; Regine Bölter; Michel Wensing

doi:10.5334/ijic.5495

Figures & Tables

Table 1

Sociodemographic characteristics of medical specialists in the qualitative study.

Variable	Medical specialists (participating) (n = 21)	Medical specialists (non-participating) (n = 11)
Sex (n (%))
male	81.0	81.8
female	19.0	18.2
Age (mean (sd))	57 (6.5)	49 (7.2)
Years of professional experience (mean (sd))	28.1 (7.0)	20.0 (7.3)
Practice based since the year… (mean (sd))	2000 (7.7)	2011 (7.3)
Vocational training (n (%))
Specialist for internal medicine	19 (90.5)	5 (45.5)
…without focus	3 (14.3)	0 (0.0)
…with focus on cardiology	16 (76.2)	5 (45.5)
Specialist for internal medicine and cardiology	3 (14.3)	5 (45.5)
Other	3 (14.3)	2 (18.2)
Practice location (n (%))
City core	11 (55.0)	7 (70.0)
Urban hinterland (~20 km)	4 (20.0)	2 (20.0)
Rural area	5 (25.0)	1 (10.0)
Type of practice (n (%))
Individual practice	6 (30.0)	7 (70.0)
Shared practice	2 (10.0)	1 (10.0)
Group practice	11 (55.0)	2 (20.0)
Ambulatory health care centre	1 (5.0)	0 (0.0)
Individual patients per quarter (n (%))
<500	0 (0.0)	1 (9.1)
500–1000	7 (33.3)	5 (45.5)
1001–1500	6 (28.6)	4 (36.4)
>1500	8 (38.1)	1 (9.1)
Full-time positions (physicians) (mean (sd))	2.9 (3.4)	1.7 (1.0)
Full-time positions (physician’s assistants) (mean (sd))	6.2 (6.1)	3.7 (2.6)
Percentage of AOK-patients participating in the medical specialist’s programme (mean (sd))	43.9 (19.3)	-
Physician’s participation in the cardiology programme since the year… (mean (sd))	2011 (1.2)	-

Table 2

Sociodemographic characteristics of medical specialists in the quantitative study.

Variable	Medical specialists (participating) (n = 75)	Medical specialists (non-participating) (n = 21)
Sex (n (%))
male	60 (80.0)	18 (85.7)
female	15 (20.0)	3 (14.3)
Age (median (IQR))	56 (51–60)	54 (45–57)
Years of professional experience (median (IQR))	28.0 (23.0–32.0)	23.0 (18.5–29.7)
Practice based since the year… (mean (sd))	2003 (8.2)	2009 (8.5)
Vocational training (n (%))
Specialist for internal medicine	62 (82.7)	16 (76.2)
…without focus	9 (13.0)	1 (4.8)
…with focus on cardiology	47 (68.1)	15 (71.4)
Specialist for internal medicine and cardiology	22 (29.3)	6 (28.6)
Other	6 (8.0)	2 (9.5)
Practice location (n (%))
City core	53 (72.6)	12 (57.1)
Urban hinterland (~20 km)	8 (11.0)	6 (28.6)
Rural area	12 (16.4)	3 (14.3)
Type of practice (n (%))
Individual practice	17 (23.6)	7 (33.3)
Shared practice	14 (19.4)	2 (9.5)
Group practice	37 (51.4)	10 (47.6)
Ambulatory health care centre	4 (5.6)	2 (9.5)
Individual patients per quarter (n (%))
<500	2 (2.7)	3 (14.3)
500–1000	34 (45.9)	10 (47.6)
1001–1500	21 (28.4)	3 (14.3)
>1500	17 (23.0)	5 (23.8)
Number of full-time positions (physicians) (mean (sd)) [n]	3.0 (2.7) [66]	2.3 (2.1) [20]
Full-time positions (physician’s assistants) (mean (sd))
0 up to 3	17 (22.7)	4 (20.0)
More than 3, up to 6	27 (36.0)	10 (50.0)
More than 6, up to 10	18 (24.0)	3 (15.0)
More than 10	13 (17.3)	3 (15.0)
Percentage of AOK-patients participating in the medical specialist’s programme (mean (sd))	19.4 (11.8)	-
Physician’s participation in the cardiology programme since the year… (mean (sd))	2012 (2.6) [60]	-

Table 3

Reasons to participate in the cardiology programme as mentioned by medical specialists.

Participation in the cardiology programme because of… (n (%))	Medical specialists (participating) (n = 75)
…receiving higher reimbursement than in regular health care	60 (80.0)
…it being an alternative to the statutory health insurance system	50 (66.7)
…it providing more diagnostic possibilities than in regular health care	25 (33.3)
…easier accounting than in regular health care	24 (32.0)
…a recommendation by the professional association	17 (22.7)
…closer cooperation with general practitioners than in regular health care	13 (17.3)
…having more time for patients than in regular health care	10 (13.3)
…a higher guideline-orientation than in regular health care	8 (10.7)
…participation of or a recommendation from colleagues	6 (8.0)
Other	8 (10.7)

Table 4

Overview of categories and subcategories of incentives to participate in the cardiology programme.

Category	Sub-category	Number of statements on the category (Number of physicians with statements)
External incentives (category had been asked for explicitly)		29 (21)
	Colleagues’ attitudes towards the cardiology programme (see section “Motivation through peers”)	27 (21)
	Advertising/peer pressure (from other physicians) ID-2: “[…] And as a physicians’ organization…and the [ORGANIZATION] was very strong in this area, they…very early they raised solidarity among physicians to some degree.”	2 (2)
Economic incentives		27 (16)
	Aspects of remuneration (see section “Economic incentives”)	20 (16)
	No cap on patient numbers in the programme ID-10: “[…] And thirdly we’re able to see more patients overall [in the cardiology programme] because in the system of the Association of Statutory Health Insurance Physicians we are budgeted regarding patient numbers.”	5 (4)
Aspects of accounting ID-4: “Yes, of course, there was dissatisfaction with accounting in the system of the Association of Statutory Health Insurance Physicians, regarding caps on numbers of cases. So, a lot of things that made you dissatisfied beforehand seemed to be better from the outset and this proved to be true for me, yes.”	2 (2)
Incentives related to reputation (category had been asked for explicitly)	(see section “Reputational benefits”)	20 (20)
Incentives related to health care		19 (11)
	Better/more services for patients through the programme (see section “Expected improvements related to health care”)	16 (9)
	More medical guideline-oriented care than regular health care ID-8: “Yeah, sure, you might adhere more strictly to guideline-oriented, rational medicine now, yes.”	2 (2)
Better cooperation with general practitioners than in regular health care ID-9: “[…] So this means, background, maybe better cooperation between general practitioner, medical specialist, a more distinct task sharing.”	1 (1)
Professional political incentives (category had been asked for explicitly)		10 (6)
	ID-2: “[…] And secondly I’ve been a long-time member of [ORGANIZATION] for political considerations. So, the whole thing was a logical consequence.”	10 (6)
	ID-13: “[…] so I remember that beforehand these scenarios of leaving the system of the Association of Statutory Health Insurance Physicians had been discussed […]. […] And so that these, let’s call it politicisations of this dispute, were already advanced. And so one of these reasons for participating in this alternative system [the cardiology programme] was definitely also a political one. […]”
Structural incentives		8 (5)
	Binding of patients ID-5: “[…] I did not want to give off patients to other colleagues, say if someone participates in the medical specialist’s programme, especially after orthopaedics and gastroenterology started, it was important to me that I could still take care of the patients I already had.”	2 (2)
	Alternative to/advancement compared to the system of the Association of Statutory Health Insurance Physicians ID-5: “Being a health economist I know that something has to change in the system of statutory health insurance physicians or in the overall health care system, that we need a paradigm shift within the health care system, that we can’t manage this through a total upheaval but need sub-steps and I classify the system of selective contracts as a small or maybe even a big step in this change in system. […]”	2 (2)
	High percentage of patients insured through AOK/Bosch BKK ID-8: “[…] sure, in the beginning only AOK was involved. […] Sure, my clientele here contains a relatively high percentage of AOK-patients, right? Sure, if you only have two percent of AOK-patients you need to think about what you’re going to do. […]”	1 (1)
	Referral within the programme is only possible between participating physicians ID-11: “[…] The situation is that only medical specialists who participate may be chosen or referred to. This was the original idea. That’s why it made sense to participate in it of course. So that general practitioners are able to refer to a medical specialist who also participates in the programme.”	1 (1)
	Taking over an already participating practice ID-12: “My predecessor was one of the first participants in the programme. I joined later and started to participate in the programme as well. So I continued with an existing system. […]”	1 (1)
	Hope for a successful implementation of software ID-8: “[…] partially, it was no insignificant effort software-wise. I had, well, since I’m practice-based I had relatively great faith in my software-provider to wangle it properly. Other colleagues had a lot more difficulties I think.”	1 (1)
Incentives related to personal background/involvement in the underlying contract		4 (3)
	ID-4: “So, of course I know [PERSON] pretty well, who was involved in negotiating the contract […]. So I witnessed a lot of things there and that influenced me of course. […] So for us it was clear from the get-go because we were very close to the origination [of the cardiology programme] and I noticed how they negotiated and so on. Just because I knew the participants in the negotiations [personally], so it was clear for us to participate from the get-go. […]”
	ID-9: “I am a member of [ORGANIZATION] and tracked the development of the contracts and also got to know the general framework during the development phase. This clearly made me decide for this kind of contract.” ID-22: “The main reason was that I’m a board member of [ORGANIZATION] and therefore was already involved in the development of the contract. […] And therefore it was clear for me to participate in the programme myself.”
	ID-22: “The main reason was that I’m a board member of [ORGANIZATION] and therefore was already involved in the development of the contract. […] And therefore it was clear for me to participate in the programme myself.”

Table 5

Reasons not to participate in the cardiology programme as mentioned by medical specialists.

No participation in the cardiology programme because of… (n (%))	Medical specialists (not participating) (n = 21)
…administrative efforts	14 (66.7)
…costs	6 (28.6)
…necessary modification of information technology	6 (28.6)
…inability or reluctance to fulfil all of the contractual terms	6 (28.6)
…fear for the survival of the statutory health insurance system	4 (19.0)
…fear for one’s professional autonomy	3 (14.3)
…professional political aspects	2 (9.5)
…a regional lack of general practitioners in general practitioner-centred care	2 (9.5)
…colleagues advised against participation	2 (9.5)
…not knowing about the cardiology contract	2 (9.5)
…a lack of suitable patients	1 (4.8)
Other	5 (23.8)

Table 6

Overview of categories and subcategories of inhibiting factors of participation in the cardiology programme.

Category	Sub-category	Number of statements on the category (Number of physicians with statements)
Structural inhibiting factors		25 (8)
	Implementation efforts (see section “Structural inhibiting factors”)	14 (7)
	New practice ID-15: “I entered the practice as recently as 2014, I entered the structures, the structures did not allow for it [the cardiology programme]. […]”	4 (4)
	Computer issues ID-14: “Furthermore I need a more powerful computer if I’m unlucky because the current one will become too slow then for the VPN, so I don’t personally see this financial benefit for me being that exorbitant I have to say.”	4 (3)
Local lack of participating patients ID-16: “[…] economically it did not pay off, there were too few patients participating. […]”	2 (1)
High percentage of private patients in practice ID-17: “So here in the practice there is, you have to say, a high percentage of private patients – right, that for sure is a reason why you say: ‘Well, okay, it [the cardiology programme] is not that vital’.”	1 (1)
External inhibiting factors (category had been asked for explicitly)		15 (11)
	Colleagues’ attitudes towards the cardiology programme (see section “External inhibiting factors”)	12 (11)
Negative experiences of colleagues ID-17: “Yes, indeed I adopted a practice. […] And with it I kind of adopted the status too, as it was conveyed to me that it [the cardiology programme] wasn’t necessarily favourable.”	3 (2)
Other inhibiting factors		15 (5)
	The programme stimulates an intentionally wrong coding of cases (see section “Other inhibiting factors”)	3 (2)
	Individual principles (see section “Other inhibiting factors”)	2 (2)
	No benefits for participating patients ID-20: “Well, the physicians receive more money, but I think that…well, I imagine that independent of the programme I don’t take worse care of non-participants than of those in the programme.”	2 (1)
	No examinations at the hospital allowed for participating physicians ID-19: “[…] for a long time, the main reason was that we, our practice, also conducted examinations with an intracardiac catheter but not in a practice but inside the hospital. And…or in the hospital here in [PLACE] and then it wasn’t possible any longer with it [the cardiology programme] back then, merely for practical reasons because it was a requirement of the programme that you, well ‘ambulatory instead of inpatient’, right? […]”	2 (1)
No benefits of the programme besides remuneration ID-20: “I think it…physicians receive more money, that’s right, but I…I can’t…I don’t see any improvement.”	1 (1)
Appointments within the programme are not prioritised by urgency ID-20: “And they come here urgently and say: ‘We need to wait for half a year’, I can’t understand it. […] this, I think, is sometimes related to the medical specialist’s programme. […] they are not insured by [health insurers offering the programme]. So, they automatically fall through the cracks which I think is highly problematic.”	1 (1)
Programme worsens physician-patient-relationship ID-18: “I think that health insurers and physicians are two separate institutions who need to fulfil their own tasks each and I think that the physician is, through these health care structures like the medical specialist’s programme, influenced sooner or later regarding autonomy so that the physician-patient-relationship is worsened.”	1 (1)
Autonomy-related inhibiting factors		13 (4)
	The programme jeopardises professional autonomy (see section “Autonomy-related inhibiting factors”)	6 (2)
	The programme restricts prescriptions (see section “Autonomy-related inhibiting factors”)	2 (2)
	The patient is bereft of their freedom of choice in physicians/therapies (see section “Autonomy-related inhibiting factors”)	2 (2)
Supervision through health insurers ID-18: “[…] you should rather allow physicians to further prescribe what they deem adequate, if they suitably continue their education, yeah. And not perform any benchmark tests or various checks by the [HEALTH INSURER] because one admits too many patients to the hospital or too few patients. Or if one’s prescribing too much drugs for heart failure or too expensive ones or too cheap ones. […]”	2 (1)
The programme contains lots of requirements ID-14: “[…] what bothered me as well, I have to say, is that this programme dictates to you a lot. […]”	1(1)
Economic inhibiting factors		3 (3)
	Disproportion of costs and earnings ID-16: “Yes, so I had to pay higher software license fees, I had to pay rent for the connecting device and what…and my assistant or we had to make a second accounting and in total everything created more work than it was good for financially.”	2 (2)
	Financial barriers Researcher: “[…] simply the investments you have to make…” ID-21: “Correct.”	1 (1)
Professional political inhibiting factors		2 (1)
	Disempowerment of the Associations of Statutory Health Insurance Physicians (see section “Professional politicial inhibiting factors”)	2 (1)