I spend a lot of time at Group Health, which is an HMO in the PacNW very similar to Kaiser. The autonomy thing is THE biggest thing holding me back from working for them. They're great, and I may end up there, but the lack of freedom is really tough.
For one, your employer is miles away, often not a doctor. They're often off counting beans (aka, RVU's) and calculating how many they can squeeze out of you. Also, the staff don't work for you, they work for that same dude nobody really knows. They give the docs I've worked with waaay too much attitude, especially when the doc falls behind.
You also have much less control over your schedule. In residency, pretty much nothing bums me out more than when a pt. is added in at the last minute, especially a complicated one. This happens all the time for me and I'm looking forward to getting some control over it once I'm out. Until you've had it happen to you, it's hard to explain how frustrating the experience is. In a private setting, taking someone on is TOTALLY up to you, and you get paid extra for doing it. In a HMO setting, it has nothing to do with you. And, in the opposite situation where you want to take an extra patient on, the staff get all mad at you because they want to go home. Their salary isn't improved by that last patient.
Also, upper management can implement anything they want at any time. The latest at Group Health is to allow the sun to rise and set on the smooth, curvy butt of Press-Ganey scores. These are *****ic patient satisfaction surveys that are so totally influenced by confounders that nobody in their right might would REALLY use the scores as actual data. But somehow the medical community is doing just that. At the HMO, your SALARY is tied to these scores. You can lose money if you spend your day telling pt's no to narcs and antibiotics and the satisfaction scores drop.
There's more, but those are the ones that jump to mind.
Crap. I just talked myself out of Group Health.
