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Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations?

Ateev Mehrotra, MD, MPH; Arnold M. Epstein, MD, MA; and Meredith B. Rosenthal, PhD
[+] Article, Author, and Disclosure Information

From University of Pittsburgh and RAND Health, Pittsburgh, Pennsylvania; and Harvard School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts.

Acknowledgments: The authors thank Sam Ho and colleagues at PacifiCare and the leaders of the physician organizations in their network for their cooperation and assistance. They also thank Alan Zaslavsky for statistical advice.

Grant Support: Data collection for this study was supported by the California HealthCare Foundation and the Commonwealth Fund. Dr. Mehrotra was supported by an institutional National Research Service Award (5 T32 HP11001-15).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ateev Mehrotra, MD, MPH, RAND Health and University of Pittsburgh School of Medicine, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665; e-mail, mehrotra@rand.org.

Current Author Addresses: Dr. Mehrotra: RAND Health and University of Pittsburgh School of Medicine, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213-2665.

Dr. Epstein: Harvard School of Public Health, Kresge Building, Room 403, 677 Huntington Avenue, Boston, MA 02115.

Dr. Rosenthal: Harvard School of Public Health, Kresge Building, Room 405, 677 Huntington Avenue, Boston, MA 02115.

Ann Intern Med. 2006;145(11):826-833. doi:10.7326/0003-4819-145-11-200612050-00007
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Leaders from 148 of the 153 physician groups were surveyed (97% response rate). The period of the study, 1999 to 2000, was a tumultuous period in the California physician market (14, 22). In the year between the survey and the quality report card, 14 (9.5%) of the physician groups went out of business and 15 (10.1%) additional physician groups merged into other organizations. Thus, PacifiCare was able to provide quality data for 119 groups.

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Integrated medical groups may not be better than individual practice associations
Posted on December 21, 2006
P Dileep Kumar
Port Huron Hospital
Conflict of Interest: None Declared

The paper by Mehrotra et al. (1) about integrated medical groups and individual practice associations on the quality of care they provide is flawed because they base their conclusions on claims data. It is well known that assuming quality standards from the data physicians submit for billing purposes is less than perfect. Moreover the paper implies that solo practitioners and small practices fare poor in quality measures because they are "˜systematically different'. This is not an encouraging comment about the 100s of practicing primary care physicians, a large majority of them are internists.

The paper also dwells extensively on electronic medical records (EMR). Considering that the study was done between 1999 and 2000, the EMR mentioned is quite rudimentary compared to the present standards. Computerized systems that included a medication list or computerized disease management systems can not be considered as EMR.

1. Mehrotra A, Epstein AM, Rosenthal MB. Do integrated medical groups provide higher-quality medical care than individual practice associations? Ann Intern Med 2006;145(11):826-33.

Conflict of Interest:

None declared

Authors' Response
Posted on January 26, 2007
Ateev Mehrotra
University of Pittsburgh
Conflict of Interest: None Declared

We agree with Dr. Kumar that using claims data to measure quality has its limitations (1), though claims data might be more accurate than medical charts for some of the quality measures we studied such as diabetic eye screening or mammograms which are conducted outside the primary care office and are tied to reimbursement.(2) The goal of our study was to compare the quality in different types of physician groups. We know of no evidence that any biases in claims data would vary systematically by type of physician group and the performance data were audited to evaluate completeness and accuracy. In speculating about potential explanations for the quality differences we found, we conjectured that one potential reason was a systematic difference in the doctors who choose to work in one type of group versus another. This idea was based in part on previous research which documented that there are differences in physicians who choose to work as employees versus independently.(3) For example, younger physicians are more likely to work as employed physicians and younger physicians generally have higher quality scores.(4) We should emphasize that the relationship we observed does not belie the fact that there are high quality physicians in independent practice associations and low quality physicians in integrated medical groups. Finally, as noted in the paper, we agree with Dr. Kumar that a limitation of our study is that the EMRs reported by groups were likely rudimentary compared to current standards.

Ateev Mehrotra, Arnold M. Epstein, and Meredith B. Rosenthal

1. Iezzoni LI. Assessing quality using administrative data. Ann Intern Med. 1997;127(8 Pt 2):666-74.

2. Diamond CC, Rask KJ, Kohler SA. Use of Paper Medical Records Versus Administrative Data for Measuring and Improving Health Care Quality: Are We Still Searching for a Gold Standard? Disease Management. 2001;4(3):121-130.

3. Kletke PR, Emmons DW, Gillis KD. Current trends in physicians' practice arrangements. From owners to employees. Jama. 1996;276(7):555-60.

4. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-73.

Conflict of Interest:

None declared

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