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.

Somos una banda: Los médicos como grupo antropológico / We are a band: an anthropological vision of the medical community

Este artículo trata de explicar cómo, desde el punto de vista antropológico, el colectivo médico se comporta como una tribu similar a las que pueblan el Amazonas o la sabana africana. La familia como unidad fundamental de la banda de cazadores define a su vez el centro de salud y a los médicos que lo habitan, como grupo igualitario en el que los miembros trabajan por el bien de la tribu. Los líderes de la tribu, también llamados directores de centro, también son similares a los grandes hombres de la Polinesia o a los aborígenes que lideran la partida de caza. Incluso los enfrentamientos entre médicos, en torno a sus competencias respecto a los pacientes, han sido descritas a lo largo de la historia por los antropólogos y repiten los patrones de los grupos segmentarios. Se concluye con que esta visión de tribus enfrentadas se ha de superar para avanzar hacia la mejora de la salud de la población

In this paper we try to explain, using an anthropological point of view, how the medical community behaves like a tribe like those who inhabit the Amazon forests or the African Savanna. The Family as fundamental unit of a band of hunter-gatherers also defines the Primary Care Centre and the professionals who work there, as an egalitarian group in which every member works for the good of the tribe. The leaders of the tribe, also called "Health Centre Managers", are also comparable to the "big men" of Polynesia or the aborigines, who leads hunting parties. Even the clashes between physicians about the responsibilities as regards patients have been described throughout history in the anthropological literature, and they repeat the patterns of the segmental groups. We finish by concluding that this vision of warring tribes has to be overcome in order to advance towards the improvement of our community's health

¿Qué hacer cuando un médico tiene problemas de salud que afectan su desempeño clínico? / What to do when a doctor presents health problems affecting his/her clinical function?

Al igual que cualquier persona, los médicos sufren de depresión que puede afectar su desempeño clínico y la seguridad de los pacientes. Para las autoridades institucionales estos problemas se traducen en un dilema entre los principios de no-discriminación y justicia hacia estos médicos y los de protección y no-maleficencia hacia los enfermos. A raíz de dos casos, los docentes de un hospital pediátrico se plantearon una serie de preguntas sobre la responsabilidad médica en esta situación, su posibilidad de estudiar medicina y las medidas a tomar; así como sobre la responsabilidad de los docentes y de los psiquiatras frente a estos médicos (confidencialidad) y a los pacientes representados por la institución. Se presentan los resultados de las entrevistas semiabiertas realizadas con estos docentes. El protocolo fue aprobado por el Comité de Bioética de Investigación de la institución

Like any person, doctors suffer from depression that may affect their clinical performance and patients’ security. For institutional authorities these problems represent a dilemma between principles of non-discrimination and justice for them, and those of protection and nonmaleficence for the patients. The first two cases in a pediatric hospital provoked the reflection of the clinical docents about medical responsibility in this situation, possibility to study medicine and measures to be taken; as well as docent and psychiatrics responsibility. The results of interview of these docents are presented. The research was approved by the Bioethics Research Committee of the institution

Cross-cultural adaptation and validation to Brazil of the scale of attitudes toward physician-pharmacists collaboration

Background: Despite the increasing complexity of medication therapies and the expansion of pharmaceutical clinical services to optimize patient care working in collaboration with physicians. In this sense, interdisciplinary education has been encouraged. However, no instrument is available to measure attitudes toward collaborative relationships. Objective: To translate, cross-cultural adaptation and validation an instrument to measure collaboration attitudes toward students of medicine/pharmacy and physicians/pharmacists. Methods: The process of cross-cultural adaptation was carried out using international recommendations and was performed from January 2014 to April 2015. The instrument under consideration was translated and re-translated. A panel of experts compared the generated documents and the translation was evaluated for 20 undergraduate students of Pharmacy, 20 undergraduate students of Medicine and professionals (20 pharmacists and 20 physicians). Results: The process of cross-cultural translation and validation result in the Portuguese version. Modifications to the grammatical structures were made in order to establish a cross-cultural similarity between the English and Portuguese versions. Regarding the evaluation of the expert panel, six questions required modifications. Conclusions: Psychometric evaluation demonstrated and confirmed the validity of the Brazilian-Portuguese version to assess collaborative attitudes among pharmacists and physicians. Moreover, the scale can be used to evaluate undergraduates and postgraduates and foster the development of teaching methods that promote comprehensive attitudes in patient care (AU)

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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.