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Hearld LR, Westra D. Charting a Course: A Research Agenda for Studying the Governance of Health Care Networks. Adv Health Care Manag 2022; 21:111-132. [PMID: 36437619 DOI: 10.1108/s1474-823120220000021006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.
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Choi SW, Dor A. Do All Hospital Systems Have Market Power? Association Between Hospital System Types and Cardiac Surgery Prices. Health Serv Res Manag Epidemiol 2019; 6:2333392819886414. [PMID: 31763372 PMCID: PMC6851608 DOI: 10.1177/2333392819886414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study explores the price implications of hospital systems by analyzing the association of system characteristics with selected cardiac surgery pricing. DATA SOURCE Using a large private insurance claim database, the authors identified 11 282 coronary artery bypass graft (CABG) cases and 49 866 percutaneous coronary intervention (PCI) cases from 2002 to 2007. STUDY DESIGN We conducted a retrospective observational study using generalized linear models. PRINCIPAL FINDINGS We found that the CABG and PCI prices in centralized health and physician insurance systems were significantly lower than the prices in stand-alone hospitals by 4.4% and 6.4%, respectively. In addition, the CABG and PCI prices in independent health systems were significantly lower than in stand-alone hospitals, by 15.4% and 14.5%, respectively. CONCLUSION The current antitrust guidelines tend to focus on the market share of merging parties and pay less attention to the characteristics of merging parties. The results of this study suggest that antitrust analysis could be more effective by considering characteristics of hospital systems.
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Affiliation(s)
- Sung W. Choi
- Health Administration, School of Public Affairs, The Pennsylvania State
University, Harrisburg, PA, USA
| | - Avi Dor
- Health Policy and Management, Milken Institute School of Public Health, The
George Washington University, Washington, DC, USA
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Rodriguez HP, Starling S, Kandel Z, Weech-Maldonado R, Moss NJ, Silver L. A taxonomy of the scope and organization of local sexually transmitted disease services for policy and practice. Int J STD AIDS 2018; 29:1375-1383. [PMID: 30071798 DOI: 10.1177/0956462418787621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Local health departments (LHDs) and their organizational partners play a critical role in controlling sexually transmitted diseases (STDs) in the United States. We examine variation in the differentiation, integration, and concentration (DIC) of STD services and develop a taxonomy describing the scope and organization of local STD services. LHD STD programs (n = 115) in Alabama (AL) and California (CA) responded to surveys assessing STD services available in 2014. K-means cluster analysis identified LHD groupings based on DIC variation. Discriminant analysis validated cluster solutions. Differences in organizational partnerships and scope of STD services were compared by taxonomy category. Multivariable regression models estimated the association of the STD services organization taxonomy and five-year (2010–2014) gonorrhea incidence rates, controlling for county-level sociodemographics and resources. A three-cluster solution was identified: (1) low DIC (n = 74), (2) moderate DIC (n = 31), and (3) high DIC (n = 10). In discriminant analysis, 95% of jurisdictions were classified into the same types as originally assigned through K-means cluster analysis. High DIC jurisdictions were more likely (p < 0.001) to partner with most organizations than moderate and low DIC jurisdictions, and more likely (p < 0.001) to conduct STD needs assessment, comprehensive sex education, and targeted screening. In contrast, contact tracing, case management, and investigations were conducted similarly across jurisdictions. In adjusted analyses, there were no differences in gonorrhea incidence rates by category. Jurisdictions in CA and AL can be characterized into three distinct clusters based on the DIC of STD services. Taxonomic analyses may aid in improving the reach and effectiveness of STD services.
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Affiliation(s)
- Hector P Rodriguez
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley, CA, USA.,Division of Health Policy and Management, UC Berkeley School of Public Health, Berkeley, CA, USA
| | | | - Zosha Kandel
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley, CA, USA
| | | | - Nicholas J Moss
- HIV STD Section, Alameda County Public Health Department, Oakland, CA, USA
| | - Lynn Silver
- Public Health Institute, Oakland, CA, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Li S, Dor A, Pines JM, Zocchi MS, Hsia RY. The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics. Med Care Res Rev 2015; 73:590-605. [PMID: 26712803 DOI: 10.1177/1077558715622897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022]
Abstract
In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.
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Affiliation(s)
- Suhui Li
- George Washington University, Washington, DC, USA
| | - Avi Dor
- George Washington University, Washington, DC, USA
| | | | | | - Renee Y Hsia
- University of California, San Francisco, CA, USA
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Piña IL, Cohen PD, Larson DB, Marion LN, Sills MR, Solberg LI, Zerzan J. A framework for describing health care delivery organizations and systems. Am J Public Health 2015; 105:670-9. [PMID: 24922130 PMCID: PMC4358211 DOI: 10.2105/ajph.2014.301926] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2014] [Indexed: 11/04/2022]
Abstract
Describing, evaluating, and conducting research on the questions raised by comparative effectiveness research and characterizing care delivery organizations of all kinds, from independent individual provider units to large integrated health systems, has become imperative. Recognizing this challenge, the Delivery Systems Committee, a subgroup of the Agency for Healthcare Research and Quality's Effective Health Care Stakeholders Group, which represents a wide diversity of perspectives on health care, created a draft framework with domains and elements that may be useful in characterizing various sizes and types of care delivery organizations and may contribute to key outcomes of interest. The framework may serve as the door to further studies in areas in which clear definitions and descriptions are lacking.
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Affiliation(s)
- Ileana L Piña
- Ileana L. Piña is with Albert Einstein College of Medicine and Montefiore-Einstein Medical Center, Bronx, NY. Perry D. Cohen is with the Parkinson Pipeline Project, Washington, DC. David B. Larson is with the Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH. Lucy N. Marion is with the Medical College of Georgia School of Nursing, Macon. Marion R. Sills is with the University of Colorado School of Medicine, Denver. Leif I. Solberg is with HealthPartners Medical Group and Clinics, Minneapolis, MN. Judy Zerzan is with the Colorado Department of Health Care Policy and Financing, Denver
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Burns LR, Wholey DR, McCullough JS, Kralovec P, Muller R. The changing configuration of hospital systems: centralization, federalization, or fragmentation? Adv Health Care Manag 2012; 13:189-232. [PMID: 23265072 DOI: 10.1108/s1474-8231(2012)0000013013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized. DESIGN/METHODOLOGY/APPROACH We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association. FINDINGS There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital. RESEARCH LIMITATIONS Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization. RESEARCH IMPLICATIONS Systems that appear to be able to centrally coordinate their services are those that operate in local or regional markets. Larger systems that span several states are likely to decentralize or fragment. PRACTICAL IMPLICATIONS System fragmentation may thwart policy aims pursued in health care reform. The potential of Accountable Care Organizations rests on their ability to coordinate multiple providers via centralized governance. Hospitals systems are likely to be central players in many ACOs, but may lack the necessary coherence to effectively play this governance role. ORIGINALITY/VALUE Not all hospital systems act in a systemic manner. Those systems that are centralized (and presumably capable of acting in concerted fashion) are in the minority and have declined in prevalence over most of the past decade.
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McHugh M, Van Dyke K, Osei-Anto A, Haque A. Medicare’s Payment Policy for Hospital-Acquired Conditions. Med Care Res Rev 2011; 68:667-82. [DOI: 10.1177/1077558711408326] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 2008, Medicare implemented a policy limiting reimbursement to hospitals for treating avoidable hospital-acquired conditions (HACs). Although the policy will expand nationally to Medicaid programs in 2011, little is known about the impact on safety net hospitals. The authors conducted interviews with 60 chief quality officers and 55 chief financial officers from safety net hospitals to explore the impact of Medicare’s HACs policy during its first year. Despite the predicted small financial impact, the authors found that the policy gained the attention of hospital leaders and many governing boards. Although the policy reportedly provided additional motivation to reduce HACs, few hospitals implemented new care practices and instead focused on documenting conditions that are present for patients on admission. The findings also illustrate the need for Centers for Medicare & Medicaid Services to provide more guidance to the industry when this type of policy is introduced.
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Affiliation(s)
| | | | - Awo Osei-Anto
- Health Research & Educational Trust, Chicago, IL, USA
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Cram P, Bayman L, Popescu I, Vaughan-Sarrazin MS, Cai X, Rosenthal GE. Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals. BMC Health Serv Res 2010; 10:90. [PMID: 20374637 PMCID: PMC2907758 DOI: 10.1186/1472-6963-10-90] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 04/07/2010] [Indexed: 01/28/2023] Open
Abstract
Background There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals. Methods We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served. Results Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth. Conclusions For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.
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Affiliation(s)
- Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Merrill J, Keeling J, Gebbie K. Toward standardized, comparable public health systems data: a taxonomic description of essential public health work. Health Serv Res 2009; 44:1818-41. [PMID: 19686248 PMCID: PMC2758408 DOI: 10.1111/j.1475-6773.2009.01015.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To identify taxonomy of task, knowledge, and resources for documenting the work performed in local health departments (LHDs). DATA SOURCES Secondary data were collected from documents describing public health (PH) practice produced by organizations representing the PH community. STUDY DESIGN A multistep consensus-based method was used that included literature review, data extraction, expert opinion, focus group review, and pilot testing. DATA EXTRACTION METHODS Terms and concepts were manually extracted from documents, consolidated, and evaluated for scope and sufficiency by researchers. An expert panel determined suitability of terms and a hierarchy for classifying them. This work was validated by practitioners and results pilot tested in two LHDs. PRINCIPAL FINDINGS The finalized taxonomy was applied to compare a national sample of 11 LHDs. Data were obtained from 1,064 of 1,267 (84 percent) of employees. Frequencies of tasks, knowledge, and resources constitute a profile of PH work. About 70 percent of the correlations between LHD pairs on tasks and knowledge were high (>0.7), suggesting between-department commonalities. On resources only 16 percent of correlations between LHD pairs were high, suggesting a source of performance variability. CONCLUSIONS A taxonomy of PH work serves as a tool for comparative research and a framework for further development.
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Affiliation(s)
- Jacqueline Merrill
- Department of Biomedical Informatics, Columbia University, Vanderbilt Clinic, New York, NY 10034, USA.
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Abstract
BACKGROUND Although many hospitals belong to health care systems, little is known about the quality of care provided by those systems, or whether characteristics of health care systems are related to the quality of care patients receive. Dimensions of the quality of care provided in 73 hospital systems were examined using hospital quality data publicly reported by the Centers for Medicare & Medicaid Services (CMS). The hospital systems consisted of six or more acute care hospitals and represented 1,510 hospitals. The study was designed to determine whether these dimensions of system quality could be reliably measured, to describe how systems varied with respect to quality of care, and to explore system characteristics potentially related to care quality. METHODS Data were made available by CMS for 19 indicators of care quality for pneumonia, surgical infection prevention, acute myocardial infarction (AMI), and congestive heart failure. RESULTS At the system level, reliable measures (alphas > .70) were constructed for each of the four clinical areas, and these measures were combined into a single measure of quality (alpha = .85). Variability in system quality was substantial, ranging from 94% to 70% on the combined quality measure. On the clinical area measures, the smallest range was for AMI (99%-85%), whereas the largest was for surgical infection prevention (95%-54%). System ownership and system centralization were significant predictors of quality, accounting for 30% of variance in the combined quality measure. Geographic region, inclusion of teaching hospitals, and system size were unrelated to quality. DISCUSSION Systems vary greatly in terms of quality of care in each of the four clinical areas, with for-profit and more decentralized systems appreciably lower in quality of care. System-level quality measures and data could be used to compare processes within systems and to drive improvement efforts.
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Affiliation(s)
- Steve Hines
- The Lewin Group, Falls Church, Virginia, USA
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