Physician commitment to organized delivery systems

Two sides to every coin: Assessing the effects of moving physicians to employment contracts

There is a growing trend of physicians becoming employees of hospital systems and employment is viewed as a mechanism to help achieve health system goals. Yet, the research is mixed on the effects of moving physicians to employment models. While the literature has traditionally placed such forms of employment relationships in opposition to professional autonomy, it has often overlooked the effects on other professional values and there is little empirical work that actually assesses how such a shift affects and is perceived by clinicians themselves. To address these gaps, we conducted a mixed method study at one hospital that recently moved all formerly self-employed physicians to employment contracts. We interviewed physicians to understand how the shift into employment was perceived to influence their work in three domains: the patient domain, the individual domain and the organizational domain. We then conducted a follow-up survey across both formerly employed and self-employed physicians to test our initial findings. We find both positive and negative effects in different domains, offering insights into the mixed results found in the current literature.

Developing an action model for integration of health system response to HIV/AIDS and noncommunicable diseases (NCDs) in developing countries

INTRODUCTION

Although there are several models of integrated architecture, we still lack models and theories about the integration process of health system responses to HIV/AIDS and NCDs.

OBJECTIVE

The overall purpose of this study is to design an action model, a systematic approach, for the integration of health system responses to HIV/AIDS and NCDs in developing countries.

METHODS

An iterative and progressive approach of model development using inductive qualitative evidence synthesis techniques was applied. As evidence about integration is spread across different fields, synthesis of evidence from a broad range of disciplines was conducted.

RESULTS

An action model of integration having 5 underlying principles, 4 action fields, and a 9-step action cycle is developed. The INTEGRATE model is an acronym of the 9 steps of the integration process: 1) Interrelate the magnitude and distribution of the problems, 2) Navigate the linkage between the problems, 3) Testify individual level co-occurrence of the problems, 4) Examine the similarities and understand the differences between the response functions, 5) Glance over the health system's environment for integration, 6) Repackage and share evidence in a useable form, 7) Ascertain the plan for integration, 8) Translate the plan in to action, 9) Evaluate and Monitor the integration.

CONCLUSION

Our model provides a basis for integration of health system responses to HIV/AIDS and NCDs in the context of developing countries. We propose that future empirical work is needed to refine the validity and applicability of the model.

Employed family physician satisfaction and commitment to their practice, work group, and health care organization

OBJECTIVE

Test a model of family physician job satisfaction and commitment.

DATA SOURCES/STUDY SETTING

Data were collected from 1,482 family physicians in a Midwest state during 2000-2001. The sampling frame came from the membership listing of the state's family physician association, and the analyzed dataset included family physicians employed by large multispecialty group practices.

STUDY DESIGN AND DATA COLLECTION

A cross-sectional survey was used to collect data about physician working conditions, job satisfaction, commitment, and demographic variables.

PRINCIPAL FINDINGS

The response rate was 47 percent. Different variables predicted the different measures of satisfaction and commitment. Satisfaction with one's health care organization (HCO) was most strongly predicted by the degree to which physicians perceived that management valued and recognized them and by the extent to which physicians perceived the organization's goals to be compatible with their own. Satisfaction with one's workgroup was most strongly predicted by the social relationship with members of the workgroup; satisfaction with one's practice was most strongly predicted by relationships with patients. Commitment to one's workgroup was predicted by relationships with one's workgroup. Commitment to one's HCO was predicted by relationships with management of the HCO.

CONCLUSIONS

Social relationships are stronger predictors of employed family physician satisfaction and commitment than staff support, job control, income, or time pressure.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration

CONTEXT

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P).

METHODS

This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration.

FINDINGS

The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians.

CONCLUSIONS

Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Successful physician-hospital integration in rural areas

OBJECTIVES

During the 1990s hospitals competed to acquire physician practices. Those competitive bidding wars could have pushed the price of practices beyond the value obtained by gaining influence over physicians. This paper examines how hospital location and competition for physician practices affects the profitability of physician-hospital integration in rural areas.

MATERIALS AND METHODS

Eight years of data covering 338 rural hospitals are used to test whether the acquisition of physician practices is more successful in more isolated, uncompetitive rural markets than in competitive rural markets. A hospital without a competitor within a 15-mile radius is deemed to operate in an uncompetitive market. Success is measured by shifts in admissions, lengths of stay, and overall profitability following the acquisition of a physician practice.

RESULTS

Hospitals in uncompetitive rural markets that acquired practices showed decreased lengths of stay and increased admissions with no reduction in profitability. Hospitals in more competitive rural markets that acquired practices showed a decrease in profitability.

CONCLUSIONS

Integration was a more profitable strategy for isolated rural hospitals than for hospitals with nearby competitors. Although further research is needed to determine if these results are due to the affect of competition on the cost of acquiring and operating practices, isolated rural hospitals should be open to the prospect of acquiring physician practices. Hospitals in competitive markets should be cautious about entering bidding wars for physician practices.

Integrated delivery networks: a detour on the road to integrated health care?

This paper reviews the rationales and evidence for horizontal and vertical integration involving hospitals. We find a disjunction between the integration rationales espoused by providers and those cited in the academic literature. We also generally find that integration fails to improve hospitals' economic performance. We offer seven lessons from hospitals' efforts to integrate and then suggest four alternative models for achieving integrated delivery of health care services.

Physician and health system integration

Incentives for vertical integration in the health care industry have led many hospitals to consolidate into health systems and profess a desire for closer alignment with affiliated physicians. In this study of fourteen organized delivery systems and their 11,000 physicians in sixty-nine medical groups, we found that many health systems did not align well with physicians. Even systems ostensibly committed to alignment emphasized structural relationships that did not enhance physician-system alignment and paid inadequate attention to issues of importance to physicians. This gap between the goal and reality of physician-system alignment appears to be the result of systems' responding to a changing mix of policies, not all of which foster integration.