Kirstin W. Scott, MPhil, PhD; E. John Orav, PhD; David M. Cutler, PhD; Ashish K. Jha, MD, MPH
This article was published at www.annals.org on 20 September 2016.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily reflect the views of the Agency for Healthcare Research and Quality or the National Science Foundation.
Acknowledgment: The authors thank Zoe Lyon, Xiner Zhou, and members of the Harvard Institute for Quantitative Social Sciences Research Technology Consulting group for their support on elements of this project.
Grant Support: At the time of this project, Dr. Scott was supported by grants T32HS00055 from the Agency for Healthcare Research and Quality and NSF 13-584 from the National Science Foundation Graduate Research Fellowship.
Disclosures: Dr. Cutler reports grants from the National Institutes of Health (NIH) during the conduct of the study; nonfinancial support from Alliance for Aging Research, Demos: A Network for Ideas and Action, University of Arizona, University of Missouri–Kansas City, Intermountain Healthcare, Kaiser Permanente, Journal of the American Medical Association, U.S. Senate, Partners Healthcare, Princeton University, New Jersey Association of Mental Health and Addiction Agencies, Spinemark, U.S. Department of Health and Human Services, The Advanced Medical Technology Association, Health Policy Commission (Commonwealth of Massachusetts), University of Chicago, Health Affairs, NIH, DuPont Children's Hospital, Symposium on U.S. Sustainable Health, National Bureau of Economic Research, Institute of Medicine, Georgia State University, Federal Reserve Bank Atlanta, The Commonwealth Fund, and Brookings Institute, outside the submitted work; personal fees from Healthcare Financial Management Association, New York City Health and Hospitals Corporation, Robert W. Baird & Co, and Bank of America Webinar, outside the submitted work; and personal fees and nonfinancial support from Novartis Princeton, MedForce, Veterans Health Administration, International Monetary Fund, National Council and Community Behavioral Healthcare, Delaware Health Sciences Alliance, Dartmouth College, Healthcare Billing and Management Association, Cadence Health, Pompeu Fabra University, Aon Hewitt, American Health Lawyers Association, Parenteral Drug Association, UBS, Aetna, Toshiba, Ernst and Young, Yale University, and New York University, outside the submitted work. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-0125.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available from Dr. Scott (e-mail, Kirstin_scott@hms.harvard.edu). Statistical code and data set: Not available.
Requests for Single Reprints: Ashish K. Jha, MD, MPH, Harvard Global Health Institute, 42 Church Street, Cambridge, MA 02138; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Scott: Harvard Interfaculty Initiative in Health Policy, 14 Story Street, 4th Floor, Cambridge, MA 02138.
Dr. Orav: Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02115.
Dr. Cutler: Littauer Center, 1805 Cambridge Street, Cambridge, MA 02138.
Dr. Jha: Harvard Global Health Institute, 42 Church Street, Cambridge, MA 02138.
Author Contributions: Conception and design: K.W. Scott, E.J. Orav, D.M. Cutler.
Analysis and interpretation of the data: K.W. Scott and E.J. Orav.
Drafting of the article: K.W. Scott, E.J. Orav, D.M. Cutler, A.K. Jha.
Critical revision for important intellectual content: K.W. Scott, E.J. Orav, D.M. Cutler, A.K. Jha.
Final approval of the article: K.W. Scott, E.J. Orav, D.M. Cutler, A.K. Jha.
Provision of study materials or patients: D.M. Cutler.
Statistical expertise: E.J. Orav.
Administrative, technical, or logistic support: K.W. Scott, D.M. Cutler, A.K. Jha.
Collection and assembly of data: K.W. Scott and D.M. Cutler.
Scott K., Orav E., Cutler D., Jha A.; Changes in Hospital–Physician Affiliations in U.S. Hospitals and Their Effect on Quality of Care. Ann Intern Med. 2016. doi: 10.7326/M16-0125
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Published: Ann Intern Med. 2016.
Growing evidence shows that hospitals are increasingly employing physicians.
To examine changes in U.S. acute care hospitals that reported employment relationships with their physicians and to determine whether quality of care improved after the hospitals switched to this integration model.
Retrospective cohort study of U.S. acute care hospitals between 2003 and 2012.
U.S. nonfederal acute care hospitals.
803 switching hospitals compared with 2085 nonswitching control hospitals matched for year and region.
Hospitals' conversion to an employment relationship with any of their privileged physicians.
Risk-adjusted hospital-level mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions.
In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. Relative to regionally matched controls, switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all P values <0.001). Up to 2 years after conversion, no association was found between switching to an employment model and improvement in any of 4 primary composite quality metrics.
The measure of integration used depends on responses to the American Hospital Association annual questionnaire, yet this measure has been used by others to examine effects of integration. The study examined performance up to 2 years after evidence of switching to an employment model; however, beneficial effects may have taken longer to appear.
During the past decade, hospitals have increasingly become employers of physicians. The study's findings suggest that physician employment alone probably is not a sufficient tool for improving hospital care.
Agency for Healthcare Research and Quality and National Science Foundation Graduate Research Fellowship.
Russell L. Bedsole
Private practice physician
September 20, 2016
I am an internist in a small private group, founded in our community over 30 years ago. Our practice is soon to become employed by the local hospital. The reason for such a paradigm shift is due largely to financial concerns, including rising overhead, diminishing insurance payments, radically expanding documentation requirements and associated costs of EMRs, etc. It is my firm belief that private practices are a dying breed, unless a complete overhaul of physician compensation is undertaken on a national level. Whether or not a change is possible or even implementable remains to be seen. Furthermore, it seems that the implication(s), whether intended or otherwise, of national guarantor policies may inculcate a health care workforce which is either supported by a single payer, or resigned to fight a losing battle in the open marketplace.
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