A more complete measure of vertical integration between physicians and hospitals.

OBJECTIVE: To develop an accurate and reproducible measure of vertical integration between physicians and hospitals (defined as hospital or health system employment of physicians), which can be used to assess the impact of integration on healthcare quality and spending. DATA SOURCES AND STUDY SETTING: We use multiple data sources including from the Internal Revenue Service, the Centers for Medicare and Medicaid Services, and others to determine the Tax Identification Numbers (TINs) that hospitals and physicians use to bill Medicare for services, and link physician billing TINs to hospital-related TINs. STUDY DESIGN: We developed a new measure of vertical integration, based on the TINs that hospitals and physicians use to bill Medicare, using a broad set of sources for hospital-related TINs. We considered physicians as hospital-employed if they bill Medicare primarily or exclusively using hospital-related TINs. We assessed integration status for all physicians who billed Medicare from 1999 to 2019. We compared this measure with others used in the existing literature. We conducted a simulation study which highlights the importance of accurately identifying integrated physicians when study the effects of integration. DATA COLLECTION/EXTRACTION METHODS: We extracted physician and hospital-related TINs from multiple sources, emphasizing specificity (a small proportion of nonintegrated physicians identified as integrated). PRINCIPAL FINDINGS: We identified 12,269 hospital-related TINs, used for billing by 546,775 physicians. We estimate that the percentage of integrated physicians rose from 19% in 1999 to 43% in 2019. Our approach identifies many additional physician practices as integrated; a simpler TIN measure, comparable with prior work, identifies only 30% (3877) of the TINs we identify. A service location measure, used in prior work, has both many false positives and false negatives. CONCLUSION: We developed a new measure of hospital-physician integration. This measure is reproducible and identifies many additional physician practices as integrated.

Clinical Outcome After Endovascular Thrombectomy in 3 Triage Concepts: A Prospective, Observational Study (NEUROSQUAD).

BACKGROUND AND PURPOSE: NEUROSQUAD (Stroke Treatment: Quality and Efficacy in Different Referral Systems) is a prospective, observational, bicenter study comparing 3 triage pathways in endovascular stroke treatment: mothership, drip and ship (DS), and transferring a neurointerventionalist to a remote hospital for thrombectomy (drive the doctor [DD]). METHODS: Patients with anterior circulation stroke and premorbid modified Rankin Scale (mRS) score 0-3 who underwent thrombectomy within 24 hours after stroke onset were included. Primary outcome measure was good clinical outcome defined as 90-day mRS score 0-2 or clinical recovery to the status before stroke onset (ie, equal premorbid mRS and 90-day mRS). Secondary outcome measures were successful reperfusion, National Institutes of Health Stroke Scale at discharge, and mRS shift. RESULTS: In total, 360 patients were included in this study, of whom 111 patients (30.8%) were in the mothership group, 204 patients (56.7%) were in the DS group, and 45 patients (12.5%) were in the DD group. Good clinical outcome was achieved similarly in all three groups (mothership, 45.9%; DS, 43.1%; DD, 40.0%; P=0.778). Likewise, frequency of successful reperfusion was similar in all three groups (mothership, 86.5%; DS, 85.3%; DD, 82.2%; P=0.714). There was no significant difference among the groups regarding the National Institutes of Health Stroke Scale at discharge (P=0.115) and mRS shift (P=0.342). In the multivariate analysis, triage concept was not an independent predictor of good outcome (unadjusted odds ratio, 0.89 [CI, 0.64-1.23]; P=0.479). CONCLUSIONS: Our data suggest that clinical outcome after thrombectomy is similar in mothership, DS, and DD. Hence, DD can be a valuable triage option in acute stroke treatment.

Do accountable care organizations differ according to physician-hospital integration?: A retrospective observational study.

ABSTRACT: Physician-hospital integration among accountable care organizations (ACOs) has raised concern over impacts on prices and spending. However, characteristics of ACOs with greater integration between physicians and hospitals are unknown. We examined whether ACOs systematically differ by physician-hospital integration among 16 commercial ACOs operating in Massachusetts.Using claims data linked to information on physician affiliation, we measured hospital integration with primary care physicians for each ACO and categorized them into high-, medium-, and low-integrated ACOs. We conducted cross-sectional descriptive analysis to compare differences in patient population, organizational characteristics, and healthcare spending between the three groups. In addition, using multivariate generalized linear models, we compared ACO spending by integration level, adjusting for organization and patient characteristics. We identified non-elderly adults (aged 18-64) served by 16 Massachusetts ACOs over the period 2009 to 2013.High- and medium-integrated ACOs were more likely to be an integrated delivery system or an organization with a large number of providers. Compared to low-integrated ACOs, higher-integrated ACOs had larger inpatient care capacity, smaller composition of primary care physicians, and were more likely to employ physicians directly or through an affiliated hospital or physician group. A greater proportion of high-/medium-integrated ACO patients lived in affluent neighborhoods or areas with a larger minority population. Healthcare spending per enrollee in high-integrated ACOs was higher, which was mainly driven by a higher spending on outpatient facility services.This study shows that higher-integrated ACOs differ from their counterparts with low integration in many respects including higher healthcare spending, which persisted after adjusting for organizational characteristics and patient mix. Further investigation into the effects of integration on expenditures will inform the ongoing development of ACOs.

Understanding the role of Foundation doctors through a self-reported time-mapping pilot study.

INTRODUCTION: There is a reduction in Foundation trainee applications to speciality training and this is attributed to an administrative job role, with subsequent fears of burnout. This pilot study presents the findings of a real-time self-reporting tool to map a group of Foundation doctors' elective activities. Self-reporting is efficient, low cost to run and allows for repeated measures and scalability. It aimed to example how a time-map could be used by departments to address any work imbalances and improve both well-being and future workforce planning. METHOD: Foundation doctors', at a busy District General Hospital, were asked to contemporaneously report their work activities over an 'elective' day. Outcomes measures included the mean duration per task and the time of day these were performed. RESULTS: Nine Foundation doctors' returned 26 timesheet days. Foundation doctors' time was split between direct patient tasks (18.2%, 106.8 min per day), indirect patient tasks (72.9%, 428.6 min per day) and personal or non-patient activities. Indirect tasks were the most frequent reason for Foundation doctors leaving late. No clinical experience was recorded at all and only an average of 4% (23.4 min per day) of a Foundation doctors' time was spent in theatre. CONCLUSIONS: This particular cohort performed a high proportion of indirect tasks. These have been associated with burnout. Time-mapping is a low-cost, acceptable and seemingly scalable way to elucidate a clearer understanding of the type of activities Foundation doctors may perform. This methodology could be used to modernise the traditional Foundation doctor job description.

How different governance models may impact physician-hospital alignment.

BACKGROUND: Hospitals utilize three ideal type models for governing relationships with their physicians: the traditional medical staff, strategic alliances, and employment. Little is known about how these models impact physician alignment. PURPOSE: The study compares the level of physician-hospital alignment across the three models. APPROACH: We used survey data from 1,895 physicians in all three models across 34 hospitals in eight systems to measure several dimensions of alignment. We used logistic equations to predict survey nonresponse and differential physician selection into the alliance and employment models. Controlling for these selection effects, we then used multiple regression to estimate the effects of alliance and employment models on alignment. RESULTS: Physicians in employment models express greater alignment with their hospital on several dimensions, compared to physicians in alliances and the traditional medical staff. There were no differences in physician alignment between the latter two models. CONCLUSIONS: Employment models promote greater alignment on some (but not all) dimensions, controlling for physician selection. The impact of employment on alignment is not large, however. PRACTICE IMPLICATIONS: Hospitals and accountable care organizations that rely on employment may achieve higher physician alignment compared to the other two models. It is not clear that the gain in alignment is worth the cost of employment. Given the small impact of employment on alignment, it is also clear that they are not identical. Hospitals may need to go beyond structural models of integration to achieve alignment with their physicians.

The Declining Presence of Family Physicians in Hospital-Based Care.

Despite training to provide care across the continuum of health delivery settings, the proportion of family physicians (FPs) reporting inpatient care has decreased by 26% between 2013 and 2017, leaving approximately 1 in 4 of FPs practicing hospital medicine in 2017. Policy makers, payers, and leaders in medical education should closely track the impact of these trends, given previous evidence associating better cost and utilization outcomes with broader scope of practice.

[The affiliated physician in Germany: the end of a cross-sector form of care?] / Das Belegarztwesen in Deutschland: Ende einer sektorenverbindenden Versorgungsform?

In the classic affiliated physician system, patients are typically guaranteed cross-sectoral surgical and nonsurgical care. For years, neutral experts have been confirming the resource-efficient use of the increasing demand for medical services due to changing demographics. Nevertheless, due to lack of support, this form of care is increasingly being replaced by structures that substitute affiliated physicians. Only by returning to this cross-sectoral form of care, which was a leading form of care up to the middle of the last century, and corresponding legislative measures will the affiliated physician form of care survive.

The Push-Pull Factors of Physician-System Integration: A Qualitative Study of Washington State Healthcare Executives.

EXECUTIVE SUMMARY: The transition from volume- to value-based care calls for closer working relationships between physician groups and health systems. Healthcare executives are in the position of determining when and how physician groups are integrated into healthcare systems. Leveraging the theory of migration, we aim to describe where physician-system integration is headed and offer recommendations on how executives can respond to physician migration to and from integration. We conducted 25 semistructured interviews with CEOs, chief medical officers, chief financial officers, and physician group chief executives from eight of Washington State's largest integrated delivery systems. These executives predicted tighter integration and more forced alignment; however, some clinician executives were skeptical about whether the physician employment model will be the right course despite the growing demand from younger physicians. The results of these interviews suggest that integration will be driven by push and pull factors stemming from five prevailing forces: social (community), social (physicians), economic, political, and technological. Understanding the factors that influence physicians' decisions to migrate can provide insight for and guidance to executives contemplating integration in the current climate.

The Employed Neurosurgeon: Essential Lessons.

Neurosurgeons are highly specialized surgeons whose pride is mastery of the complexity of form and function that is the nervous system and then knowing when and how these require surgical intervention. Following years of arduous postgraduate education, neurosurgeons enter the world of practice that is not only daunting in its intricacies of regulations, mandates, and unknown business practices, but also changing at a meteoric pace. Overwhelmingly, graduating residents and fellows are choosing to practice as employed physicians, a trend that is new in its magnitude and also changed because of the rapid evolution of large health systems. Case studies of challenges other employed surgical specialists have faced can provide critical and important education for any neurosurgeon in this arena. As with the lessons of all case studies, the teachings are remarkably universal, but how those lessons apply to an individual's specific situation will require personalized adaptation.

A Review and Survey of Neurosurgeon-Hospital Relationships: Evolution and Options.

As healthcare delivery shifts from fee-for-service, episodic care to pay for performance and population health, both hospitals and physicians are looking for new forms of integration. A number of regulations and restrictions govern physician relationships with hospitals. In this paper, we review the legal basis for such relationships and the options available. We also survey neurosurgeons and hospital executives to gain their perspective on the current situation and likely future. Two series of structured interviews were conducted with 10 neurosurgeons who work in a range of situations in diverse markets, and with Memorial Hermann Healthcare System senior executive leadership. Their responses form the basis for the subsequent discussion. Neurosurgeons can be independent, join a confederation such as an Independent Physician Association or another type of "clinically integrated" network, or be employed by a hospital, medical school, or physician group. With varying levels of integration comes the strength of size, management expertise, negotiating leverage, economies of scale, and possibly financial advantages, but with impact on autonomy and independence. Constructive alignment can lead to a win-win situation for both the individual physician and the organization, but options vary widely due to heterogeneous local conditions. This paper reviews possible relationships, moving along a spectrum from no financial integration to full integration. Concepts such as physician leasing, professional service agreements, "clinical integration," and employment are presented. This paper offers a practical reference that might be useful to a new graduate, independent neurosurgeon considering integration, or employed physicians considering alternatives.

Role of family physicians in an urban hospital: Tracking changes between 1977, 1997, and 2014.

OBJECTIVE: To investigate changes in family doctors' attitudes about and participation in hospital activities and inpatient care in an urban hospital family medicine department from 1977 to 1997 and 2014. DESIGN: Cross-sectional survey design. SETTING: The Department of Family Medicine at St Joseph's Healthcare Hamilton in Ontario. PARTICIPANTS: Family physicians affiliated with the Department of Family Medicine at St Joseph's Healthcare Hamilton were surveyed in 2014. Data were compared with findings from similar surveys administered at this institution in 1977 and 1997. MAIN OUTCOME MEASURES: Family physicians' roles in hospital activities, attitudes toward the role of the family physician in the hospital setting, and the barriers to and facilitators of maintaining this role. RESULTS: A total of 93 physicians returned completed surveys (37.3% response rate). In 2014, half of the respondents provided some inpatient care. This patient care was largely supportive and newborn care (71.7% and 67.4%, respectively). In 2014, 47.3% believed the quality of care would suffer (compared with 92.1% in 1977 and 87.5% in 1997) if they were not involved in patient care in the hospital. There was also a considerable shift away from the 1977 and 1997 perception that the family physician had a role as patient advocate: 92.0% and 95.3%, respectively, compared with only 49.5% in the 2014 survey. CONCLUSION: Family physicians' hospital activities and attitudes continued to change from 1977 to 1997 and 2014 in this urban hospital setting. Most of the respondents had stopped providing direct inpatient care, with a few continuing to provide supportive care. Despite this, most respondents still see a role for the Department of Family Medicine within the hospital as a focus for identifying with their family physician community, a place to interact with other specialist colleagues, and a source of some continuing medical education.