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In Germany the looming shortage of physicians has been an important health policy issue in recent years. The German Federal Medical Association (GFMA), the joint association of the 17 state chambers of physicians in Germany, reports residents in some rural areas—particularly in eastern Germany—to be considered medically underserved (Kopetsch 2006). The GFMA expects a rising physician shortage, since 19 percent of the practicing physicians will retire within 5 years, and some study results show fewer medical school graduates intending to work in clinical medicine (Rieser 2005; Gensch 2007; Kopetsch 2008. Several studies describe physicians' job satisfaction as presumably a key factor influencing remaining in the medical workforce. For example, “the level of remuneration,”“the general workload,”“the extent of administrative work,”“the collaboration with colleagues,”“the balance of work and family,”“the extent of responsibility in the decision making process,” and “continuing education” seem to impact job satisfaction (Gensch 2007; Janus et al. 2007, 2008; Laubach and Fischbeck 2007;Brähler, Alfermann, and Stiller 2008).
Concerning the physician shortage's effect on health care, the Association of Health Insurance Physicians (AHIP) of the federal state of Saxony-Anhalt, a less densely populated state in Eastern Germany, described rural areas with five general practitioners per 10,000 inhabitants, with 33 percent aged 60 or above (Kassenärztliche Vereinigung Sachsen-Anhalt 2009). Another indicator of limited health care access is waiting time for consultations, with up to 33 days on average in some rural areas of Eastern Germany compared with 12 days in urban areas of Berlin (Betriebskrankenkassen Ost 2008). Particularly in Eastern Germany the state AHIPs reported that patients' traveling distances for medical care and the use of nonphysician services like nurse practitioners has increased. In conclusion, the AHIPs have questioned whether ambulatory care can be secured in the future. Yet studies about whether, for example, nurse practitioners are a cost-effective alternative to physicians for treating simpler medical conditions and how much such nonphysician services affect the quality of care are still missing.
In contrast to these indications of physician shortage, the Organization for Economic Cooperation and Development (OECD) reported the total number of physicians per capita in Germany increased in the last years, averaging 3.4 practicing physicians per 1,000 population, compared with a 3.0 average in OECD countries (Simoens and Hurst 2004). Considering this, one could assume that the problem of physician shortage in Germany is not necessarily due to a lack of physicians in general but to an unequal distribution (Klose, Uhlemann, and Gutschmidt 2003; Simoens and Hurst 2004. This means physicians tend to practice in urban or affluent rural areas, whereas other areas have difficulties attracting enough physicians to provide high-quality health care to the residents. This “maldistribution” of physicians is perceived in many countries, including the United States, the United Kingdom, Australia, and Canada (Joyce, McNeil, and Stoelwinder 2004; Rosenthal, Zaslavsky, and Newhouse 2005; Robertson et al. 2007.
In Germany health policy makers have addressed the “maldistribution” of physicians with many interventions, tending to improve the diffusion of physicians either by regulation or by incentive-based programs. Monetary incentive-based programs were implemented, including improved remuneration plans or the donation of seed capital for practice establishment. Little evidence in the literature favors the long-term success of such programs (Sempowski 2004), and health policy makers are thinking about programs focusing more on physician life-style concerns, for example, the number of on-call duties. To date very few studies have explored the role of monetary and nonmonetary attributes in practice establishment. The present study aimed to provide information for health policy makers about the importance of different attributes and their combinations related to practice establishment.
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METHODS
The study used a preference-based approach to derive information about attributes relevant for practice establishment: in a hypothetical scenario a practice alternative is described by several attributes at different levels, and respondents choose the most and the least preferred attributes at a respective level (see Figure 1). This choice task is repeated according to an experimental design plan for a set of practice alternatives and is called “best worst scaling” (BWS) (Finn and Louviere 1992; Flynn et al. 2007.
Figure 1
Example of a Best–Worst Scaling (BWS) Task
BWS belongs to the discrete choice experiments (DCE) applied to measure preferences in health care issues, like estimation of patient benefit in health technology assessment, analysis of patient or professional decision making, and developing prioritization frameworks (Ryan et al. 2001). Preferences derived from BWS tasks have strong roots in economic theory and design of experiments and have the advantage of giving preference information on the attribute's impact (attribute utility weight) and on its levels (level scale utility weight) (Flynn et al. 2007). This quantification informs about how the attributes and their levels are related to each other. For health policy makers, “level scale utility weights” are often more interesting—they illustrate implications of policy decisions by quantifying changes from one level to the other. Attribute utility weights indicate the impact of the attribute itself, but since attributes do not change across decision scenarios, their policy relevance is rather limited. Since all estimated level scale utilities lie on a common scale, marginal rates of substitution (MRS) can be calculated (Flynn et al. 2007). The MRS describe the rates for respondents willingly giving up one attribute in exchange for another, and the present study uses them to describe the relation of nonmonetary attributes to a monetary attribute. Thus, MRS provide health policy makers with information about the utility of different attributes and their combinations to develop tailored incentive-based programs.
The present study involved the following steps: (1) identifying a set of attributes relevant to the establishment of a practice, (2) generating the BWS task using an experimental design plan, (3) determining the sampling procedure, and (4) estimating the utility of the attributes and their respective levels.
Identifying the Attributes
Attributes relevant to the establishment of a practice were identified, described and labeled to ensure the BWS task encompassed the most relevant attributes by executing a qualitative study interviewing 22 physician in-depth. All physicians were randomly selected at two university hospital campuses, one in Eastern Germany (Leipzig) and the other in Western Germany (Münster). The interviewed physicians had not yet established a practice but intended to. Briefly, the qualitative process identifying relevant attributes was a multistep funnel-shaped process. At first a brainstorming task was conducted, collecting all potentially relevant attributes. In the following process the number of attributes was reduced stepwise based on interviewees' attitudes concerning the relevance of practice establishment. This was achieved with the repertory grid technique (Fransella, Bell, and Bannister 2004) and the laddering technique (Gutman and Reynolds 1988) during the in-depth interviews; both techniques helped the interviewee distinguish between attributes concerning relevance to establish a practice. In addition to the attributes, interviewed physicians determined discrete observable levels in sufficient detail, allowing to distinguish in the BWS task between attributes related more to a rural practice or to an urban practice. In the last step, all attributes and their levels were evaluated by two established physicians, selected at the authors' convenience, to be realistic concerning development of policy (Coast and Horrocks 2007).
Experimental Design
The number of attributes and their levels identified during the qualitative process determined the total set of possible practice alternatives. Using the complete set, that is a full factorial design, the number of choices required from each respondent soon becomes enormous as the number of attributes and/or levels increases. To minimize respondents' burdens, an orthogonal main effects plan (OMEP) was used, reducing the number of practice alternatives shown in the experiment (Burgess and Street 1994). The appropriate experimental design plan was developed with the software SAS and the macro Mktex. The final questionnaire had 24 different practice alternatives, allowing estimation of all main effects of the attributes and their levels (Flynn et al. 2007). Using the BWS task utility, weights of the attributes and their respective levels were estimated.
Sampling Procedure
With databases of five state chambers of physicians, we identified physicians who had not yet established their own practice. Since this information was not directly specified in the database, all physicians with (1) no completed training in any specialty and (2) younger than 40 years were sampled. The first sample criterion was based on specialization as a prerequisite for licensing by the AHIP when establishing a practice. Consequently, this criterion ensured that sampled physicians had not yet established an AHIP-licensed practice. The second criterion was chosen because most physicians not completing specialty training by age 40 never do so, mainly because specialization is not required for their work, for example, in industry or health service administration. Thus, both criteria should ensure that the survey went only to physicians likely to face a future decision on practice establishment.
Fourteen thousand nine hundred and thirty-nine questionnaires were mailed to 4,689 physicians from the state chamber of Lower Saxony, 3,287 physicians from the state chamber of Saxony, 3,212 physicians from Westphalia-Lippe, 1,887 physicians from Mecklenburg Western Pomeranian, and 1,864 physicians from Saxony-Anhalt. All samples were full samples except for Westphalia-Lippe, which consisted of a random subsample of all 4,812 identified physicians. With Westphalia-Lippe and Lower Saxony, two chambers of Western Germany and with Saxony, Saxony-Anhalt, Mecklenburg Western Pomeranian three chambers of Eastern Germany participated in the study. Within the context of the study, one should know the struggle of the Eastern German economy since unification in 1989, and large subsidies still go from west to east mainly to support the infrastructure policy.
The present study based sample size calculation on a simulation study (Flynn et al. 2007). Considering that further subgroup analysis stratified by sociodemographic characteristics in each state chamber would be performed, each subgroup should have at least 150 physicians to achieve an R2 of 0.95 in the regression analysis of up to eight attributes. A questionnaire pretest was conducted with 15 physicians not already having their own practice. These were selected at the authors' convenience; all physicians were completing training for speciality at the University of Leipzig. Questionnaires were sent out in August 2007; a reminder followed after 14 days.
Statistical Analysis
As suggested by Flynn (Flynn et al. 2007), inferences about the utility scale based on the BWS tasks were made with the “paired model approach,” aggregating the choice frequencies of all possible best–worst pairs at a sample level followed by an adjustment eliminating sampling zeros. According to the experimental design plan, the levels of attributes with fewer levels appeared more often in the BWS task than in attributes with more levels. This influences the probability of a particular best–worst pair being chosen (Flynn et al. 2007). Therefore, the frequency of choosing a best–worst pair was adjusted by its availability in the BWS task.
The utility weights of the attributes and their levels were estimated by weighted least square regression. The weights used in regression analysis were the frequencies of the choice totals adjusted to eliminate zeros. Since the natural log of the frequency of a best–worst pair chosen is a linear function of the difference in utilities, the dependent variable (cf) in the regression model was represented by the logarithm of the adjusted choice frequencies. The explanatory variables were formed by a set of dummy-coded variables representing the weight of attributes (AT1–AT6) and a set of effect-coded variables representing the level scale utilities of the attributes (AT1_level1–AT6_level4). Formally, the regression model is described
Fifty-four percent of the interviewed physicians were female and the group mean age was 33.4 [standard deviation (SD)=2.5]. About 41 percent grew up in an urban area and about 91 percent of respondents intended to establish a practice, in about 4 years on average.
Briefly, the analysis of the in-depth interviews revealed the following concepts relevant to the establishment of a practice: professional cooperation, income, family, leisure, and workload. In detail, the interviewed physicians stated feeling a lack of experience in conducting a practice, both in urban and in rural areas. The possibility to reassure diagnostic decisions in the treatment of patients was also very important. Additionally, almost all interviewed physicians were concerned about the economic risks related to the financial investment of practice establishment. The attribute “professional cooperation” addressed these concerns with different types of practices reflecting the level of cooperation.
The qualitative analysis identified “income” as a significant attribute influencing the decision to establish a practice. Here, income was the monthly net income after tax in Euro (1€=U.S.$1.32). The lowest level reflected the average income of a young physician working as an assistant in hospital. The highest level reflected an above-average income compared with a typical general practitioner in Germany (Statistisches Bundesamt 2003).
Issues about the “career opportunities of the partner” and the “availability of child care” were considered important in most interviews with particular focus on establishing a practice in rural areas. Interviewed physicians stated that the partner's workplace or child care should not be far from practice location. Ideally, the workplace of the partner or the child care should be on-site, it should never be further than 60 minutes driving time. Briefly, physicians tended to combine aspects of private life with professional life, for example, interviewed physicians viewed the choice of practice location against the background of childcare availability, since it is seen as an advantage to pick up the children directly after work.