Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-refl ecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.T he consolidation of hospitals and physicians has been changing the landscape of health care delivery in the United States. Prior literature on consolidation has focused on hospital systems, vertical integration, and market concentration from the hospital or physician perspective. [1][2][3] Less attention has been devoted to provider consolidation from the system perspective and the diverse mix of vertically integrated health systems that vary by size, ownership type, and geographic scope. 4 Building on prior work, 5 this study addressed several questions: How did the consolidation of providers into health systems change from 2016 to 2018? How did the number of systems and system size change? How did the landscape of health systems vary by ownership type in 2018?Using national data, we found that the share of primary care physicians affiliated with vertically integrated health systems increased from 38 percent to 49 percent, or 11 percentage points, from 2016 to 2018 (exhibit 1). In 2018 more than half of all physicians and 72 percent of hospitals were affiliated with one of the 637 health systems identified in the Compendium of US Health Systems from the Agency for Healthcare Research and Quality (AHRQ). Exhibit 1Percent of physicians, primary care physicians, hospitals, and hospital beds affiliated with vertically integrated health systems in the US, 2016 and 2018 SOURCE Authors' analysis of data for 2016 and 2018 from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and from IQVIA OneKey. NOTE Hospitals and hospital beds refer to US nonfederal general acute care hospitals.

Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.

Health care delivery systems are a growing presence in the U.S., yet research is hindered by the lack of universally agreed-upon criteria to denote formal systems. A clearer understanding of how to leverage real-world data sources to empirically identify systems is a necessary first step to such policy-relevant research. We draw from our experience in the Agency for Healthcare Research and Quality’s Comparative Health System Performance (CHSP) initiative to assess available data sources to identify and describe systems, including system members (for example, hospitals and physicians) and relationships among the members (for example, hospital ownership of physician groups). We highlight five national data sources that either explicitly track system membership or detail system relationships: (1) American Hospital Association annual survey of hospitals; (2) Healthcare Relational Services Databases; (3) SK&A Healthcare Databases; (4) Provider Enrollment, Chain, and Ownership System; and (5) Internal Revenue Service 990 forms. Each data source has strengths and limitations for identifying and describing systems due to their varied content, linkages across data sources, and data collection methods. In addition, although no single national data source provides a complete picture of U.S. systems and their members, the CHSP initiative will create an early model of how such data can be combined to compensate for their individual limitations. Identifying systems in a way that can be repeated over time and linked to a host of other data sources will support analysis of how different types of organizations deliver health care and, ultimately, comparison of their performance.

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Objective To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration. Data Sources Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database. Study Design We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital‐based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018. Data Collection/Extraction Methods We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization. Principal Findings Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology‐oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital‐systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians’ potential contribution to hospital revenue, and investor‐owned systems demonstrated more limited physician integration. Conclusions Variation in physician integration across markets and system characteristics reflects physician and systems’ motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low‐income populations).

This appendix document provides additional details on the construction of key variables from our analysis that are not in AHRQ's publicly available Compendium of U.S. Health Systems and Hospital Linkage file. 1 We also describe the process by which we used web searches to link academic medical centers (AMCs) to medical school affiliates.