Health maintenance organization penetration and the practice location choices of new physicians - A study of large metropolitan areas in the United States

OBJECTIVES. The rapid growth of health maintenance organizations is reshaping the practice opportunities available to physicians. The practice location decisions of new physicians provide a sensitive bellwether of these changes. This study assessed the effect of health maintenance organization penetration on practice location for physicians completing graduate medical education (GME). METHODS. Conditional legit regression analysis was used to determine the effect of health maintenance organization penetration on practice location, controlling for other market characteristics. Subjects were physicians who finished GME between 1989 and 1994 and who located in one of the 98 US metropolitan areas with more than 500,000 population. The outcome measure was the particular metropolitan area chosen by each new physician. RESULTS. Early in the study period, new generalists were significantly more likely to locate in metropolitan areas with high health maintenance organization penetration than in low penetration areas, whereas new specialists' practice location choices were not associated with health maintenance organization penetration. The likelihood of choosing a high penetration relative to a low penetration area declined with time, however, for both generalists and specialists. Consequently, by the end of the study period, health maintenance organization penetration had a weak but significant negative effect on practice location for generalists and a strong negative influence on practice location for specialists. CONCLUSIONS. New generalists who completed graduate medical education between 1989 and 1994 were more likely than new specialists to locate in market areas with high health maintenance organization penetration; however, the proportions of both generalists and specialists who chose high penetration areas decreased during the study period. This finding may reflect reduced practice opportunities in high penetration areas relative to low penetration areas as health maintenance organizations' systems for controlling utilization began to yield results. Alternatively, new physicians may have become more hesitant to accept available positions in high penetration areas.