The promise and peril of health systems

Kronick, Richard

doi:10.1111/1475-6773.13595

Cited by 7 publications

(9 citation statements)

References 8 publications

(15 reference statements)

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“…Structural integration is likely to continue within American health care, and incentives embedded in the payment system will continue to matter (Kronick, 2020). But even well-intended systems under optimal payment conditions may fail to deliver integrated frontline care when facing the operational challenges of integration.…”

Section: Discussionmentioning

confidence: 99%

“…Using two novel surveys administered to a national sample of managers, clinicians and staff across multiple practices within 17 health systems, we measure normative and interpersonal integration and explore their association with provider experience, perceived care quality and clinical process integration. Amid great interest in both the promise and the peril of health systems (Kronick, 2020), our research indicates the potential for social features of integration to help elucidate the conditions under which health systems might generate value.…”

Section: Introductionmentioning

confidence: 98%

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Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

et al. 2021

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More is known about the structural features of health system integration than the social features—elements of normative integration (alignment of norms) and interpersonal integration (collaboration among professionals and with patients). We surveyed practice managers and 1,360 staff and physicians at 59 practice sites within 17 health systems (828 responses; 61%). Building on prior theory, we developed and established the psychometric properties of survey measures describing normative and interpersonal integration. Normative and interpersonal integration were both consistently related to better provider experience, perceived care quality, and clinical integration (e.g., a 1-point increase in a practice’s normative integration was associated with 0.53-point higher job satisfaction and 0.77-point higher perceived care quality in the practice, measured on 1 to 5 scales, p < .01). Variation in social features of integration may help explain why some health systems better integrate care, pointing to normative and interpersonal integration as potential resources for improvement.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 98%

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

et al. 2021

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“…During the COVID-19 pandemic, physician receptivity to joining health systems increased . Integrated systems of care have the potential to improve quality and efficiency through care coordination and use of information technology, but also have greater market power to negotiate higher prices …”

Section: Introductionmentioning

confidence: 99%

Organization and Performance of US Health Systems

Beaulieu

Chernew

McWilliams

et al. 2023

JAMA

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ImportanceHealth systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.ObjectiveTo (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.Evidence ReviewHealth systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare &amp; Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.FindingsA total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with &gt;100 beds), as were system physician practices (74% vs 12% with &gt;100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.Conclusions and RelevanceIn 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.

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“…Health systems have the potential to improve quality and efficiency, but also erode clinician autonomy while making health care more expensive and less responsive to patients. 41 Health care consolidation often means vertical integration-1 or more hospitals plus medical groups within a single ownership structure. 42 From 2012 to 2018, the proportion of physicians employed by hospitals rose from 26% to 44%.…”

Section: Telehealthmentioning

confidence: 99%

Revitalizing Primary Care, Part 2: Hopes for the Future

Bodenheimer

2022

Ann Fam Med

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Part 1 of this essay argued that the root causes of primary care's problems lie in (1) the low percent of national health expenditures dedicated to primary care and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access. Part 2 explores policies and practice changes that could solve or mitigate these primary care problems.Initiatives attempting to improve primary care are discussed. Diffuse multi-component initiatives-patient-centered medical homes (PCMHs), accountable care organizations (ACOs), and Comprehensive Primary Care Plus (CPC+)-have had limited success in addressing primary care's core problems. More focused initiatives-care management, open access, and telehealth-offer more promise.To truly revitalize primary care, 2 fundamental changes are needed: (1) a substantially greater percent of health expenditures dedicated to primary care, and (2) the building of powerful teams that add capacity to care for large panels while reducing burnout.Part 2 of the essay reviews 3 approaches to increasing primary care spending: state-level legislation, eliminating Medicare's disparity between primary care and procedural specialty reimbursement, and efforts by health systems. The final section of Part 2 addresses the building of powerful core and interprofessional teams.

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The promise and peril of health systems

Cited by 7 publications

References 8 publications

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

Social Features of Integration in Health Systems and Their Relationship to Provider Experience, Care Quality and Clinical Integration

Organization and Performance of US Health Systems

Revitalizing Primary Care, Part 2: Hopes for the Future

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