Patients' Ratings of Outpatient Visits in Different Practice Settings

Abstract

Objective. —To determine how patients in different kinds of practices—solo or single specialty (SOLO), multispecialty group (MSG), or health maintenance organizations (HMOs)—and with fee-for-service (FFS) or prepaid physician payment arrangements evaluate their medical care. Design. —Survey of adult outpatients after office visits, with sample weighted to represent population of patients visiting physicians in each practice type. Setting. —Offices of 367 internists, family practitioners, endocrinologiste, cardiologists, and nurse practitioners, in HMOs (prepaid only), MSGs (prepaid and FFS), and SOLO practices (prepaid and FFS). Patients. —Adults (N=17671) at start of the Medical Outcomes Study. Outcome Measures. —Overall rating of the visit (five choices from excellent to poor). A random half of the sample also rated the provider's technical skills, personal manner, and explanations of care as well as time spent during the visit, the appointment wait, the office wait, the convenience of the office location, and telephone access. Results. —Fifty-five percent of patients rated their visit overall as excellent, 32% very good, 11% good, and 2% fair or poor. Patients of SOLO practitioners were more likely (64%) to rate their visit excellent than MSG (48%) or HMO (49%) patients (P<.001 ). Patients of SOLO practitioners rated all aspects of care better than HMO patients did, most markedly appointment waits (64% vs 40% excellent;P<.0001) and telephone access (64% vs 33% excellent;P<.0001). Within SOLO and MSG practices, FFS patients rated most specific aspects better than prepaid patients, but these differences were not statistically significant and were inconsistent across cities. Adjusting for patients' demographics, diagnoses and self-rated health did not change results. Physicians with visit ratings in the lowest 20% were nearly four times as likely to be left by patients within 6 months than physicians in the highest 20% (16.7% vs 4.6%;P<.001). Conclusion. —Of the five practice type and payment method combinations, SOLO FFS patients rated their visits best and HMO patients worst. Whether FFS or prepaid, care was rated better in small than in large practices. Our study shows that a brief visit rating form can be used to compare practice settings and health plans, and that patient ratings predict what proportion of patients, on average, will leave their physicians in the next several months. (JAMA. 1993;270:835-840)