Switching Doctors: Predictors of Voluntary Disenrollment from a Primary Physician’s Practice

Discussion

In our observational study of insured employed adults, 20% of the patients voluntarily left their primary care physician’s practice over a 3-year period. Another 5% left involuntarily, owing to factors that forced a change (eg, the physician moved, retired, or died). For the average full-time primary physician, this translates into approximately 400 patients voluntarily leaving the practice over a given 3-year period and another 100 leaving involuntarily. Rates of involuntary switching are almost certainly higher among physicians whose patients face more employer-imposed disruptions than occurred in our study population.

Our data indicate that the quality of the physician-patient relationship significantly predicts patients’ loyalty. With patient characteristics and structural features of care taken into account, those with the poorest-quality physician-patient relationships in 1996 were 3 times more likely to leave the physician’s practice over the ensuing 3 years than those with the highest-quality relationships.

Structural features of care also emerged as important determinants of patients’ disenrollment decisions. When considered independently of relationship quality, each of the 4 structural elements of care significantly predicted voluntary disenrollment. With relationship quality taken into account, continuity of care (both relationship duration and visit-based continuity) remained significant predictors of disenrollment, while access to care and integration of care did not. The results suggest that although these patients put a high priority on being given timely and convenient access to their physician’s office, the issue of who they are given access to and the quality of their connection with that clinician mattered more.

Our findings are consistent with those reported more than 2 decades ago by Kasteler and colleagues,¹⁶ who found both interpersonal quality of care and structural features of care to be significantly associated with voluntary physician switching in a cross-sectional study. Our study has the advantage of longitudinal data through which the sequencing of effects is clear. In addition, our study advances beyond earlier studies that evaluated a single patient-based measure of care in predicting disenrollment.^17,25 Marquis and coworkers¹⁷ showed that patients’ general satisfaction with their physician predicted disenrollment from the physician’s practice over the following year. Thom and colleagues²⁵ found that patients’ trust in their physicians significantly predicted disenrollment over the next 6 months. Our study includes measures of 8 characteristics that encompass the defining features of primary care as posited by the IOM1 and others,^26-29 with several features for which the relationship to disenrollment have not been previously studied. Our study contributes evidence concerning both the absolute and relative importance of interpersonal and structural features of care as predictors of patients’ loyalty to their primary care physician’s practice.

Limitations

Our study is limited to a population of adults in Massachusetts who were employed and insured at baseline. Rates of involuntary physician switching in this population were likely lower than would be observed in other employed populations (particularly in competitive health care markets) for the reasons mentioned (ie, benefit policies that minimized employer-imposed disruption of employees’ health care arrangements). However, the observed rates of voluntary physician switching and the predictors of voluntary disenrollment should not be affected. Those findings may be presumed to generalize more broadly.

A second limitation is the absence of information about salient health events that occurred between the baseline and follow-up phases of our study. For patients who incurred a serious episode of illness, information about the intervening health events and their experiences with their physician during that time might have enhanced our understanding of the factors that influenced their decisions about whether to remain in that physician’s practice.

Similarly, the study lacked detailed indicators of the technical quality of care provided and therefore could not assess the role that technical quality—and patients’ perceptions of it—play in shaping patients’ loyalty to their physician.

Finally, our study could not fully account for one potential source of involuntary disenrollment: patients leaving practices because the physicians no longer accepted their health plan. However, rates of physician turnover during the study period were no more than 5% in any of the health plans studied and were substantially lower in most.²¹ Thus, our findings are unlikely to have been substantively altered by a detailed accounting of this form of involuntary physician switching.

Conclusions

Previous empirical research has underscored the importance of physician-patient relationship quality by demonstrating its association with important outcomes, including adherence to medical advice,^19,30-32 satisfaction with care,^19,33-35 and litigation against physicians.^36-38 However, few studies have had the benefit of longitudinal data with which to verify the sequencing of effects between relationship quality and outcomes.

In our study the strength of physician-patient relationships in primary care—as indicated by patients’ trust in their physician, their assessments of how well the physician knows them, and the quality of communication and interpersonal treatment—was the leading predictor of patients’ loyalty to their primary physician’s practice. Continuity of care also significantly predicted voluntary disenrollment. The findings are noteworthy against a backdrop of health care delivery changes nationwide that many describe as threatening the therapeutic alliance between the physician and the patient.^29,39-42