OBJECTIVES: To assess the level and determinants of African-American physicians' employment in health maintenance organizations (HMOs), particularly early in their careers. METHODS: We analyzed data from the 1991 and 1996 Young Physicians Surveys to assess racial differences in the likelihood of HMO employment (n = 3,705). Using multinomial logistic regression, we evaluated four explanations for an observed relationship between African-American physicians and HMO employment: human capital stratification among organizations, race-based affinity between physicians and patients, financial constraints due to debt burden, and different organizational hiring practices. Using binomial logistic regression, we also evaluated differences in the odds of being turned down for a prior practice position, of subsequently leaving the current practice organization and of later having career doubts. RESULTS: Without any controls, African-American physicians were 4.52 times more likely to practice in HMOs than Caucasian physicians. After controlling for human capital stratification, racial concordance and financial constraints, African-American physicians remained 2.48 times more likely to practice in HMOs than Caucasian physicians. In addition, 19.2% of African-American physicians in HMOs reported being turned down for another job, far more than any other racial/ethnic group in the HMO setting and any racial/ethnic group, including African-American physicians in the non-HMO setting (including all other practice locations). Five years later, those same African-American physicians from HMOs also reported significantly more turnover (7.50 times more likely than non-HMO African-American physicians to leave their current practice) and doubt about their careers (2.17 times more likely than non-HMO African-American physicians to express serious career doubts). CONCLUSIONS: African-American physicians were disproportionately hired into HMO settings, impacting their subsequent careers
