Hospital-physician relationships: imperative for clinical enterprise collaboration

The need for new venues for physician-hospital collaboration is significant and growing, especially between independent physicians and health systems. Often physicians and hospitals act independently of each other, even though maintaining and sustaining a productive relationship between physicians and hospitals is essential to good patient care and improving the health status of the communities we serve. The tension in physician-hospital relationships is a long-standing and widely acknowledged concern. The old model of hospital-physician relationships, governed by the rules of the organized medical staff structure, doesn't work in the current environment, which has grown increasingly complex as a result of economic, legal, and care-delivery changes. These complexities make relationship management challenging. Hospitals and physicians struggle to align behaviors to achieve cost and quality goals. The need has never been greater for hospitals and physicians to work together as a joint clinical enterprise to improve quality, reduce practice variation, and control the cost of healthcare. This article explores the challenges and some options for improving the physician-hospital relationship in the current environment.     

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.     

Hospital-physician integration: case studies of community hospitals.

Hospitals are attempting more meaningfully to involve physicians in management as one approach to increasing the efficiency and effectiveness of their operations. The purpose of this research was to explore the relationship between the structure of the medical staff organization, the extent to which physicians are integrated into hospital decision making and the hospital's financial performance. A measure of hospital-physician integration was developed based on Alexander et al's (1986) dimensions of hospital-physician integration which were based on Scott's (1982) organizational models, ie, autonomous, heteronomous and conjoint. A multiple case study design, which comprised eight community non-teaching hospitals over 200 beds located in the Province of Ontario, Canada, was used to examine the relationship between variables. Study results suggest that there is variation among community hospitals on both contextual and organization factors. Hospitals with high levels of hospital-physician integration were located in highly populated areas, had formulated and implemented a strategic plan, had highly structured medical staff organizations, and had no budgetary deficit. In contrast, hospitals with moderate or low levels of integration were more likely to be located in lowly populated areas, had little planning activity, had a moderately structured medical staff organization, and had deficit budgeting. Suggested areas for future research include examining the role of the Board of Trustees in determining physicians' organizational roles and identifying differences in commitments, characteristics, and motivations of physicians working in rural versus urban hospitals and their impact on integrative strategies.     

Hospital-physician relations: two tracks and the decline of the voluntary medical staff model

Data from the most recent Community Tracking Study (CTS) interviews in twelve nationally representative metropolitan areas indicate that hospitals are increasingly employing physicians, particularly specialists. Nonemployed physicians are separating from hospitals passively by refusing to serve on medical staff committees or take emergency department call, and actively by creating specialized facilities, such as ambulatory surgery centers (ASCs), to compete for hospitals' most profitable services. Employment is more common and physician-owned ASCs are less common in consolidated hospital markets. The interviews also suggest other factors motivating physician employment by, or separation from, hospitals, and likely consequences of these trends.     

Innovative modeling of naturalistic driving data: Inference and prediction

Naturalistic driving studies provide opportunities for investigating the effects of key driving exposures on risky driving performance and accidents. New technology provides a realistic assessment of risky driving through the intensive monitoring of kinematic behavior while driving. These studies with their complex data structures provide opportunities for statisticians to develop needed modeling techniques for statistical inference. This article discusses new statistical modeling procedures that were developed to specifically answer important analytical questions for naturalistic driving studies. However, these methodologies also have important applications for the analysis of intensively collected longitudinal data, an increasingly common data structure with the advent of wearable devises. To examine the sources of variation between- and within-participants in risky driving behavior, we explore the use of generalized linear mixed models with autoregressive random processes to analyzing long sequences of kinematic count data from a group of teenagers that have measurements at each trip over a 1.5-year observation period starting after receiving their license. These models provide a regression framework for examining the effects of driving conditions and exposures on risky driving behavior. Alternatively, generalized estimating equations approaches are explored for the situation where we have intensively collected count measurements on a moderate number of participants. In addition to proposing statistical modeling for kinematic events, we explore models for relating kinematic events with crash risk. Specifically, we propose both latent variable and hidden Markov models for relating these 2 processes and for developing dynamic predictors of crash risk from longitudinal kinematic event data. These different statistical modeling techniques are all used to analyze data from the Naturalistic Teenage Driving Study, a unique investigation into how teenagers drive after licensure.     

Reconsideration of discharge data to measure competition in the hospital industry

Economists have long used state-collected discharge data to construct Hirschman-Herfindahl (HH) indices measuring hospital competition. Since data are collected to determine the facility providing the service rather than ownership, the difference between the number of reporting facilities and the number of competitors has grown over time due to mergers and networking activities. Consequently, the validity of the discharge HH methodology, as currently employed, is in doubt. Comparing the annual census of New York state acute-care hospitals by the State and the American Hospital Association (AHA), we find that it is increasingly important to account for changes in ownership when constructing such indices.     

Moral deliberation: the role of methodologies in clinical ethics

The experience of the last thirty years has shown that whether the different methodologies used in clinical ethics work well or not depends on certain external factors, such as the mentality with which they are used. This article aims to analyze two of these mentalities: the “dilemmatic” and the “problematic.” The former uses preferably the decision-making theory, whilst the latter emphasizes above all the role of deliberation. The author considers that Clinical Ethics must be deliberationist, and that only in this context the different methodologies can be used correctly. This revised version was published online in July 2006 with corrections to the Cover Date.     

Hospital-physician joint ventures: a strategic approach for both dimensions of success

Joint ventures between hospitals and the physicians on their medical staffs have produced successes and failures. Each joint venture has two very different dimensions of success--financial and collaborative. The most successful ventures are able to accomplish both of these often conflicting goals. To enhance hospital executives' success in joint ventures with physicians, a strategic approach with a series of six steps and their corresponding models or maps is proposed. The steps in this strategic approach are: (1) identify key stakeholders and linkages among them; (2) surface stakeholder conflict using problem-oriented maps; (3) diagnose the venture on both dimensions of success; (4) classify the venture using both dimensions of success; (5) select a strategy to optimize the venture's current potential for success; and (6) select an approach to transform the venture with limited potential for success.