Evaluating opportunities for direct contracting between employers and physician-hospital organizations

Employers seeking to reduce health care expenditures are turning to direct contracting as a way to control provider cost increases. In a direct contract, the participation of third parties is minimized. The health care provider and a corporate buyer directly negotiate a price agreement for the delivery of health care services. However, as managed care penetration increases, the ability of hospitals and physicians to assume risk while providing high quality, cost effective care will be paramount. Physicians and hospitals who choose to work together may find a physician-hospital organization an effective vehicle to meet the current and future market challenges of direct contracting.     

Physician-hospital networking: avoiding a shotgun wedding.

The erosion of the traditional market is forcing hospitals and physicians to reevaluate their historical relationships. One method for addressing the potential conflicts created by current pressures is the formation of physician-hospital networks. These entities are formed and function on the basis of mutual interests and responsiveness to change.     

Driving forces behind integration: weigh your options

Collaborative relationships between hospitals and physicians can take many forms. Before you choose your strategy, consider the benefits and drawbacks of each. Many of America's hospitals and physicians are rushing to integrate their services through a variety of collaborative options. Their haste has been encouraged by many factors. Before hospitals and physicians react to the driving forces around them, they should carefully consider the pros and cons of four types of collaborative options: 1. management service organizations, 2. physician-hospital organizations, 3. practice acquisition models, 4. equity models.     

Health care reform and emergency department services

EDs are the access of last resort for many Americans, and cost-driven reform initiatives that restrict ED utilization could deter people from seeking necessary and timely medical services. The experience in Canada under universal coverage suggests that major reform could lead to a substantial increase in ED utilization, especially in view of the relative shortage of primary care physicians in the United States. Many hospitals could face short-term overcrowding problems that compromise the quality of care provided in EDs, and rural hospital EDs face specific and unique problems relative to competition and cost efficiency. Integration of emergency services into comprehensive health delivery systems under the concept of managed competition is essential to ensure access and cost-effective delivery of services. The hospital ED may well serve as an important focal point in the development of alternative physician-hospital relationships.     

Assessing the extent of integration achieved through physician-hospital arrangements

In this article we examine management service organizations (MSOs), physician-hospital organizations (PHOs), hospital-affiliated independent practice associations (IPAs), and hospital-sponsored "group practices without walls" (GPWWs) that allow physicians to retain their practices and link hospitals and health systems to physicians through contractual arrangements. Also examined were medical foundations (MFs), integrated salary models (ISMs), and integrated health organizations (IHOs) that own the physical assets of physician practices and contract with payors for physician and hospital services. The research provides several new insights for understanding the structure and process of physician-hospital integration. It was found that the extent of processual integration in physician-hospital organizational arrangements can be measured along six dimensions: administrative and practice management services; physician financial risk-sharing; joint ventures to create new services; computer linkages; physician involvement in strategic planning; and salaried physician arrangements. These dimensions are consistent with the conceptual and empirical dimensions developed by others. These findings refute the notion raised by some industry observers that the new physician-hospital organizational models simply formalize integrative activities already in place. Earlier studies from the 1980s reported that hospitals integrated physicians through involvement in governance, capital planning, and the provision of practice management services. In contrast, we found that current integration.     

建立专科医师流动层 促进医院整体医疗质量提高

2002年以来,采用“培训合约制”的方式向社会招收培训医师,在3年培训结束后实行二次就业,一部分医师流动到其它县市医院工作,从而在医院形成一个住院医师的流动层。至2008年12月,医院已先后接纳228名培训医师进行培训,这些培训医师成为承担临床一线医疗任务的主要力量。在现有医院医师编制无法改变的情况下,通过建立专科医师流动层的方式,扩大医院住院医师队伍,可以在一定程度上改变目前大型公立医院医师群体“倒金字塔”的畸形状况,充实扩大相对固定的住院医师群体,成为医院整体医疗质量提高的重要保证。经过这一严格培训过程的专科医师求职到其它不同级别医院工作,对基层医疗单位医疗质量的提高也发挥非常积极的作用。     

Is the quality of hospital care a function of leadership?

Multiple regression analysis was used to evaluate the relationship between hospital quality and independent variables of interest. While past studies have analyzed hospital efficiency to evaluate organizational performance, this study is unique because it evaluates the relationship between quality and efficiency. The study incorporates an independent variable, "efficiency," calculated using a variable returns-to-scale, input-oriented, data envelopment analysis methodology. This article provides an innovative approach to measuring cost and quality as the federal government attempts to realign scarce health care resources to better meet local community needs. Data for 143 hospitals in 2000 were analyzed using multiple regression and data envelopment analysis to evaluate hospital quality. These results have managerial implications related to improving hospital quality as well as enhancing organizational performance. The study has policy implications on the relationship between quality and efficiency and supports current initiatives related to pay-for-performance in the health care industry. This study clearly documents the positive relationship between quality and efficiency, which supports the premise that hospital leadership through the effective allocation of resources and development of high-performance work processes is important to improve quality of care.     

The effect of hospital control strategies on physician satisfaction and physician-hospital conflict.

This article examines several strategies that hospitals use to control their medical staffs. Such strategies include placing physicians on salary, developing exclusive hospital affiliations with physicians, and involving physicians in decision-making bodies. Using regression techniques, we investigate which hospitals are more likely to utilize these strategies and whether such strategies are effective in promoting physician-hospital integration. Contrary to our expectations, corporate hospital structures (e.g., for-profit hospitals, membership in multihospital systems) generally do not employ these strategies more often and oftentimes employ them less. There is also little evidence that control strategies are effective levers for increasing physician satisfaction or decreasing physician-hospital conflict. We suggest that control strategies are useful for purposes other than promoting physician-hospital integration. Finally, hospital ownership appears to exert the biggest effect on physician satisfaction and conflict.     

健康、技术、改革与发展的关系

该文论述了健康与发展的关系，技术与卫生发展的关系，改革与卫生发展的关系。指出卫生系统的组织和筹资策略是保证人人享有卫生保健的重要手段，保障人民健康是政府的责任；政府对社区医疗服务的质量和公平性应该加强监督与立法；只有改变卫生服务提供方（医院、医师）的行为，将改革支付方式作为改革的重点，才能取得控制费用和改善健康的双重效果。     

"Virtual" health care organizations and the challenges of improving quality

This article examines the challenges of improving health care quality continuously within and across "virtual" provider organizations such as independent practice associations and physician-hospital organizations. It draws on recent research and theory about interorganizational networks in other fields to develop recommendations for securing physicians' commitment to quality improvement strategies in today's health care environment.     

A trust relationship. A medical advisory board builds physician commitment to a healthcare facility

Today physicians and hospitals are in competition. To ensure consistent physician input and a forum for two-way communication, St. Edward Mercy Medical Center, Fort Smith, AR, has established a medical staff board. The medical staff board was organized so physicians could formally address managers' concerns without duplicating work done by other medical staff committees (e.g., executive committee, medical staff sections, hospital committees). Membership on the 24-member board was limited to the active staff. A two-year term was established, allowing for two consecutive terms to ensure continuity. The chief of staff and chief executive officer (CEO) are ex-officio members. Some of the issues of interest to physicians include how well informed operating room personnel were on current technology and procedures, how effective the emergency department could be, having been designed almost 20 years ago, and how volume purchasing affects physician familiarity with certain products. St. Edward's medical staff board has the potential to enhance the physician-hospital relationship and to serve as an effective tool in building commitment to the medical center.     

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.     

Just how integrated are integrated delivery systems? Results from a national survey

This article examines three emergent processes in physician-hospital integrated delivery systems (IDSs). We find these processes are underdeveloped based on data gathered from a national sample of hospitals drawn from nine health care systems. These processes are also loosely coupled with the structures used to integrate physicians and hospitals, as well as with the environmental context in which they occur. Such loose coupling entails both advantages and disadvantages for IDSs.     

Cost inefficiency under financial strain: a stochastic frontier analysis of hospitals in Washington State through the Great Recession

The importance of increasing cost efficiency for community hospitals in the United States has been underscored by the Great Recession and the ever-changing health care reimbursement environment. Previous studies have shown mixed evidence with regards to the relationship between linking hospitals’ reimbursement to quality of care and cost efficiency. Moreover, current evidence suggests that not only inherently financially disadvantaged hospitals (e.g., safety-net providers), but also more financially stable providers, experienced declines to their financial viability throughout the recession. However, little is known about how hospital cost efficiency fared throughout the Great Recession. This study contributes to the literature by using stochastic frontier analysis to analyze cost inefficiency of Washington State hospitals between 2005 and 2012, with controls for patient burden of illness, hospital process of care quality, and hospital outcome quality. The quality measures included in this study function as central measures for the determination of recently implemented pay-for-performance programs. The average estimated level of hospital cost inefficiency before the Great Recession (10.4 %) was lower than it was during the Great Recession (13.5 %) and in its aftermath (14.1 %). Further, the estimated coefficients for summary process of care quality indexes for three health conditions (acute myocardial infarction, pneumonia, and heart failure) suggest that higher quality scores are associated with increased cost inefficiency.     

A conceptual framework for evaluating joint venture opportunities between hospitals and physicians.

This paper reviews the changes in the competitive and regulatory environment and examines the impact of those changes on the relationships between hospitals and physicians. Transaction cost economics (TCE) provides a conceptual framework for examining the emergence of closer linkages between hospitals and physicians than the traditional independent hospital and medical staff organisations. TCE predicts that as investments in support of transactions become more specialised, closer linkages are more efficient. To illustrate, two case studies of successful hospital-physician joint ventures are presented. The first case study describes a joint venture between hospitals and physicians to purchase durable medical equipment. The second case describes the breakdown of an informal arrangement and the subsequent formation of a joint venture to organise a clinical programme. The discussion reports the rationale for choosing these structural arrangements and their key features, pointing out how TCE would account for the decision to establish a joint venture. The conclusion discusses the implications of this argument for the strategic decisions of health care managers.     

Psychosocial challenges facing physicians of today

Fundamental changes in the organization, financing, and delivery of health care have added new stressors or opportunities to the medical profession. These new potential stressors are in addition to previously recognized external and internal ones. The work environment of physicians poses both psychosocial, ergonomic, and physico-chemical threats. The psychosocial work environment has, if anything, worsened. Demands at work increase at the same time as influence over one's work and intellectual stimulation from work decrease. In addition, violence and the threat of violence is another major occupational health problem physicians increasingly face. Financial constraint, managed care and consumerism in health care are other factors that fundamentally change the role of physicians. The rapid deployment of new information technologies will also change the role of the physician towards being more of an advisor and information provider. Many of the minor health problems will increasingly be managed by patients themselves and by non-physician professionals and practitioners of complementary medicine. Finally, the economic and social status of physicians are challenged which is reflected in a slower salary increase compared to many other professional groups. The picture painted above may be seen as uniformly gloomy. In reality, that is not the case. There is growing interest in and awareness of the importance of the psychosocial work environment for the delivery of high quality care. Physicians under stress are more likely to treat patients poorly, both medically and psychologically. They are also more prone to make errors of judgment. Studies where physicians' work environment in entire hospitals has been assessed, results fed-back, and physicians and management have worked with focused improvement processes, have demonstrated measurable improvements in the ratings of the psychosocial work environment. However, it becomes clear from such studies that quality of the leadership and the physician team impact on the overall work atmosphere. Physicians unaware of the goals of the department as well as the hospital, that do not receive management performance feedback, and who do not get annual performance appraisals and career guidance, rate their psychosocial environment as more adverse than their colleagues. There is also a great need to offer personally targeted competence development plans. Heads of department and senior physicians rate their work environment as of higher quality than more junior and mid-career physicians. More specifically, less senior physicians perceive similar work demands as their senior colleagues but rate influence over work, skills utilization, and intellectual stimulation at work as significantly worse. In order to combat negative stressors in the physicians' work environment, enhancement initiatives should be considered both at the individual, group, and structural level. Successful resources used by physicians to manage the stress of everyday medicine should be identified. Physicians are a key group to ensure a well-functioning health care system. In order to be able to change and adapt to the ongoing evolution of the Western health care system, more focus needs to be put on the psychosocial aspects of physicians' work.     

Hub-and-spokes regionalization. The teaching hospital should be the hub of its healthcare market

To remain viable, teaching hospitals must be horizontally and vertically integrated, multilevel healthcare delivery systems. Such integration is needed for a teaching hospital to remain the hub of its urban or rural regional healthcare market and to generate sufficient fiscal resources to support its medical education programs, research activities, quality of care, and innovative technology. Teaching hospital trustees, physicians, and managers must evaluate an increasing number of alternatives to improve quality of patient care, maximize educational and research opportunities, and increase revenues. These options include merging with community hospitals and improving relationships between community physicians and teaching hospitals and their full-time clinical faculty. To ensure long-term viability, teaching hospitals may need to use an approach that concurrently employs a hub-and-spokes arrangement, a horizontal and vertical diversification, and a multilevel healthcare delivery system configuration.     

Ambulatory care growth: implications for academic organizations

This article discusses the implications of the dramatic growth of outpatient activity in academic health care organizations, and, more broadly, in all forms of joint physician-hospital outpatient care. The authors describe several economic, operational, and regulatory factors that influence the success of ambulatory care expansion in the academic environment. A case study of the Metropolitan New York Medicaid managed care environment illustrates the impact of these factors and highlights the specific challenges confronting teaching hospitals and physicians. The attributes of ambulatory care providers that have successfully addressed these challenges are also discussed. Finally, the benefits of the model ambulatory practice structure, employed at a number of teaching institutions across the country, are explored.     

The RBRVS and hospitals: the physician payment revolution on our doorstep

As the months count down to the scheduled Jan. 1, 1992, implementation of Medicare physician payment reform, physicians and hospital administrators are still uncertain as to precisely how the new payment rules will affect them. But when it does kick in, the Health Care Financing Administration's implementation of the resource-based relative value scale (RBRVS) is sure to transform both physician reimbursement and physician-hospital relations. Experts expect HCFA to use the RBRVS to raise reimbursement for primary care at the expense of specialty care; that could lead to tension between hospitals and specialty physicians, as those specialists pressure hospitals to help them make up for income losses. What's more, HCFA is already planning for the possibility that specialists hit by the RBRVS will raise their Medicare volume to recoup reimbursement declines. Just how successfully an individual hospital weathers the coming payment revolution will depend on its mix of specialties and its medical staff relationships. It's also clear, according to experts, that RBRVS implementation will create a strong incentive for hospitals to enter joint ventures or other arrangements with physicians for outpatient services.     

RBRVS apprehension may be an administrative red herring

"The RBRVS has been accepted as a rational and systematic approach to determining fees for physician services. By adopting this method, the federal government has corrected the distorted incentive structure for physician payment, and has provided itself and others another tool with which to build an improved health-care system." The words of RBRVS architect and Harvard School of Public Health economist Dr. William C. Hsiao are receiving mixed reviews from health-care administrators and strategic planning consultants. While RBRVS is gaining some respect among health-care practitioners for lowering the cost of Medicare services, an unexpected ramification is developing. Many physicians are avoiding the administrative paperwork of another federal medical program by joining physician-hospital alliances where hospitals are luring physician fidelity with administrative incentives.