Organizational approaches to integrated health care delivery: a taxonomic analysis of physician-organization arrangements

Environmental and Organizational Factors Associated with Hospital Use of GPO Services

Given the potential benefits of Group Purchasing Organizations in cost-containment efforts for hospitals on supplies and purchased services, an important question that remains unanswered is what conditions support or hinder the utilization of GPOs by hospitals. Therefore, this study explores the relationship between GPO use by hospitals and their market and organizational characteristics. Data on hospital GPO utilization and other organizational characteristics were combined with secondary hospital market characteristics. Panel logistic regression with random effects and state and year fixed effects analysis was used to examine the relationship between hospitals' utilization of GPO services and hospitals' organizational and market characteristics. Overall, the majority of hospitals utilized the services of GPOs. Specifically, the number of hospitals utilizing the services of GPOs increased slightly from 3290 (72.2%) in 2004 to 3337 (74.4%) in 2013. In regression analyses, hospitals utilizing the services of GPOs operated in an external environment with mixed levels of munificence, more dynamism, and less competition. Specifically, hospitals operating in a less munificent environment are more likely to utilize the services of GPOs. The study findings provide organizational decision-makers and policymakers' insights into how certain market and organizational factors influence hospital strategy choice, in this case, the use of GPOs.

An empirical typology of private child and family serving agencies

Differences in how services are organized and delivered can contribute significantly to variation in outcomes experienced by children and families. However, few comparative studies identify the strengths and limitations of alternative delivery system configurations. The current study provides the first empirical typology of private agencies involved with the formal child welfare system. Data collected in 2011 from a national sample of private agencies were used to classify agencies into five distinct groups based on internal management capacity, service diversification, integration, and policy advocacy. Findings reveal considerable heterogeneity in the population of private child and family serving agencies. Cross-group comparisons suggest that differences in agencies' strategic and structural characteristics correlated with agency directors' perceptions of different pressures in their external environment. Future research can use this typology to better understand local service systems and the extent to which different agency strategies affect performance and other outcomes. Such information has implications for public agency contracting decisions and could inform system-level assessment and planning of services for children and families.

A taxonomy of nursing care organization models in hospitals

BACKGROUND

Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features.

METHODS

This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units' profile data.

RESULTS

The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses' professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses' perceptions that the practice environment is less supportive of their professional work.

CONCLUSIONS

This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an "ideal" nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms

PURPOSE

To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.

DESIGN/METHODOLOGY/APPROACH

Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants' success and effects on patient care.

FINDINGS

Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.

LIMITATIONS

This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes.

PRACTICAL IMPLICATIONS

Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support.

ORIGINALITY/VALUE

We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

Understanding the organization of public health delivery systems: an empirical typology

CONTEXT

Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.

METHODS

This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.

FINDINGS

Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.

CONCLUSIONS

Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Interprofessional partnerships in chronic illness care: a conceptual model for measuring partnership effectiveness

INTRODUCTION

Interprofessional health and social service partnerships (IHSSP) are internationally acknowledged as integral for comprehensive chronic illness care. However, the evidence-base for partnership effectiveness is lacking. This paper aims to clarify partnership measurement issues, conceptualize IHSSP at the front-line staff level, and identify tools valid for group process measurement.

THEORY AND METHODS

A systematic literature review utilizing three interrelated searches was conducted. Thematic analysis techniques were supported by NVivo 7 software. Complexity theory was used to guide the analysis, ground the new conceptualization and validate the selected measures. Other properties of the measures were critiqued using established criteria.

RESULTS

There is a need for a convergent view of what constitutes a partnership and its measurement. The salient attributes of IHSSP and their interorganizational context were described and grounded within complexity theory. Two measures were selected and validated for measurement of proximal group outcomes.

CONCLUSION

This paper depicts a novel complexity theory-based conceptual model for IHSSP of front-line staff who provide chronic illness care. The conceptualization provides the underpinnings for a comprehensive evaluative framework for partnerships. Two partnership process measurement tools, the PSAT and TCI are valid for IHSSP process measurement with consideration of their strengths and limitations.

An empirical taxonomy of hospital governing board roles

OBJECTIVE

To develop a taxonomy of governing board roles in U.S. hospitals.

DATA SOURCES

2005 AHA Hospital Governance Survey, 2004 AHA Annual Survey of Hospitals, and Area Resource File.

STUDY DESIGN

A governing board taxonomy was developed using cluster analysis. Results were validated and reviewed by industry experts. Differences in hospital and environmental characteristics across clusters were examined.

DATA EXTRACTION METHODS

One-thousand three-hundred thirty-four hospitals with complete information on the study variables were included in the analysis.

PRINCIPAL FINDINGS

Five distinct clusters of hospital governing boards were identified. Statistical tests showed that the five clusters had high internal reliability and high internal validity. Statistically significant differences in hospital and environmental conditions were found among clusters.

CONCLUSIONS

The developed taxonomy provides policy makers, health care executives, and researchers a useful way to describe and understand hospital governing board roles. The taxonomy may also facilitate valid and systematic assessment of governance performance. Further, the taxonomy could be used as a framework for governing boards themselves to identify areas for improvement and direction for change.

Nurse staffing levels: impact of organizational characteristics and registered nurse supply

OBJECTIVE

To assess the impact of nurse supply in the geographic areas surrounding hospitals on staffing levels in hospital units, while taking into account other factors that influence nurse staffing.

DATA SOURCES

Data regarding 279 patient care units, in 47 randomly selected community hospitals located in 11 clusters in the United States, were obtained directly from the hospitals from the U.S. Census report, National Council of State Boards of Nursing, and The Centers for Medicare and Medicaid Services.

STUDY DESIGN

Cross-sectional analyses with linear mixed modeling to control for nesting of units in hospitals were conducted. For each patient care unit, the hours of care per patient day from registered nurses (RNs), LPNs, nursing assistants, and the skill-mix levels were calculated. These measures of staffing were then regressed on type of unit (intensive care, medical/surgical, telemetry/stepdown), unit size, hospital complexity, and RN supply.

PRINCIPAL FINDINGS

RN hours per patient day and RN skill mix were positively related to intensity of patient care, hospital complexity, and the supply of RNs in the geographic area surrounding the hospital. LPN hours, and licensed skill mix were predicted less reliably but appear to be used as substitutes for RNs. Overtime hours increased in areas with a lower RN supply. Vacancy and turnover rates and the use of contract nurses were not affected by nurse supply.

CONCLUSIONS

This study is the first to show that hospital RN staffing levels on both intensive care and nonintensive care units decrease as the supply of RNs in the surrounding geographic area decreases. We also show that LPN hours rise in areas where RN supply is lower. Further research to describe the quality of hospital care in relation to the supply of nurses in the area is needed.

Recruitment of Physicians To Rural America: A View Through the Lens of Transaction Cost Theory

CONTEXT

Many rural hospitals in the United States continue to have difficulties recruiting physicians. While several studies have examined some of the factors affecting the nature of this problem, we know far less about the role of economic incentives between rural providers and physicians.

PURPOSE

This conceptual article describes an economic theory of organization called Transaction Cost Theory (TCT) and applies it to rural hospital-physician relationships to highlight how transaction costs affect the type of contractual arrangement used by rural hospitals when recruiting physicians.

METHODS

The literature is reviewed to introduce TCT, describe current trends in hospital contracting with physicians, and develop a TCT contracting model for analysis of rural hospital-physician recruitment.

FINDINGS

The TCT model predicts that hospitals tend to favor contractual arrangements in which physicians are full-time employees if investments in physical or other assets made by hospitals cannot be easily redeployed for other services in the health care system. Transaction costs related to motivation and coordination of physician services are the key factors in understanding the unique contractual difficulties faced by rural providers.

CONCLUSIONS

The TCT model can be used by rural hospital administrators to assess economic incentives for physician recruitment.

How physicians' organizations compete: protectionism and efficiency

This article develops a framework that distinguishes four types of competitive strategies that physicians' organizations can adopt in their interactions with health plans. Two types of strategies protect physicians' incomes and autonomy from incursion and control by insurers; the other two enhance the efficiency of health care markets by controlling costs and embedding physicians' caregiving in a community of professionals. The mix of strategies that each organization adopts at any given time depends on the market conditions and regulatory policies it faces, as well as its organizational capacity. The article reviews recent developments in the field that indicate that today's markets and regulations create neither the pressures nor the capacity for physicians' organizations to adopt strategies that enhance efficiency. The managed care backlash has led to a relaxation of pressures to control costs, and the lack of a business case for quality has discouraged embedded caregiving. These developments instead have encouraged and enabled physicians' organizations to adopt strategies that protect their members from the bargaining power and micromanagement of health plans. The article therefore proposes changes in purchasing and regulatory policies to alter the pressures and improve the capacity of physicians' organizations to pursue efficiency and eschew protectionism.

Something old, something new: recent developments in hospital-physician relationships

OBJECTIVE

To describe recent developments in hospital-physician relationships in 12 metropolitan areas.

METHODS

We analyze qualitative data from a third round of biannual site visit interviews conducted in 12 randomly selected metropolitan areas from 1996 to 2001. The study interviewed 895 respondents during the third round of site visits, conducted in 2000 and 2001.

PRINCIPAL FINDINGS

As HMO enrollment and capitation contracting has failed to grow in local markets, hospital executives have returned to a strategic focus on improving relationships with specialists in pursuit of fee-for-service revenue. Yet, 65 percent of hospitals interviewed in 2000 and 2001 continued to own primary care physician practices, with ownership more prevalent in highly concentrated hospital markets. A majority (55 percent) of hospitals have decreased the size of these practices in the past two years.

CONCLUSIONS

Interest in forming integrated delivery systems has waned. The potential for quality improvement through these organizations systems--by emphasizing primary care and coordinating hospital and physician services--has not been realized. The new emphasis on hospital-specialist partnerships may improve the financial status of hospitals and participating specialists in local markets, and may improve quality of care in selected service areas, but it may also increase health care costs incurred by employers and consumers.

A longitudinal perspective on health plan-provider risk contracting

During the past decade many health plans adopted risk-contracting arrangements that transferred substantial financial risk and care management responsibility to physician groups and hospital-sponsored integrated delivery systems. Risk transfer arrangements are now believed to be in steep decline, but there is little empirical evidence on this topic, particularly at the local-market level. Data from the Community Tracking Study were used to examine changes in risk contracting from 1996 to 2000. A decline in reliance on risk contracting is evident in nearly all markets. However, retrenchment in risk contracting has followed different patterns ranging from refinements in the scope of risk transfer to reduced use of risk arrangements to total rejection of risk-sharing arrangements. Modified risk-transfer agreements remain viable in several markets, but continued refinement in the nature and scope of risk sharing will be necessary.

Is hospital case management a rationalized myth?

In this article the adoption of case management processes in US hospitals is discussed. While such process change is prevalent, there is a paucity of systematic empirical evidence that hospital case management improves efficiency or effectiveness. Using an institutional theoretical framework, motivations other than improved efficiency and effectiveness are proposed that may drive hospitals to adopt change to their technical core processes, in the form of case management. Further research using these propositions as an adjunct to cost-benefit analyses would be important to validate the rationale behind the widespread adoption of hospital case management processes.

CEO perceptions of competition--and strategic response in hospital markets

Physician-organization integration (POI) has emerged as a key issue for hospitals and health systems seeking to improve the quality and cost-effectiveness of care. Although competition and managed care are often cited as primary market drivers of the adoption of POI strategies, prior research has shown only weak associations between these market attributes and POI. This article argues that the role of key organizational decision makers has not been adequately accounted for in explaining strategic change. The study examines the role of hospital CEO perceptions of competition in predicting the adoption of five different approaches to POI. CEO perceptions of general market competition are explained by a combination of market and organizational attributes. Furthermore, when controlling for objective characteristics of the environment and organization, CEO perceptions of competition have consistent, statistically significant associations with four of five measures of POI examined.

Just how integrated are integrated delivery systems? Results from a national survey

This article examines three emergent processes in physician-hospital integrated delivery systems (IDSs). We find these processes are underdeveloped based on data gathered from a national sample of hospitals drawn from nine health care systems. These processes are also loosely coupled with the structures used to integrate physicians and hospitals, as well as with the environmental context in which they occur. Such loose coupling entails both advantages and disadvantages for IDSs.

The effects of structure, strategy and market conditions on the operating practices of physician-organization arrangements

Research to date has documented weak or inconsistent associations between market and organizational factors and the adoption of physician-organization arrangements (POAs) (e.g. physician-hospital organizations, management service organizations and independent practice associations) designed to increase physician integration. We argue that POAs may mask considerable variation in how these entities are operated and governed. Further, because the operating policies and practices of POAs are likely to influence more directly the behaviour of physicians than the structural form of the POA, they may be more sensitive to the market and organizational contingencies that encourage integration. This study attempts to test empirically the relative effects of POA type and market, strategic and organization factors on the operating policies and practices of market-based POAs. Results suggest that type of POA, and market, strategic and organizational factors affect risk sharing, physician selection practices, physician monitoring practices and ways in which monitoring information is used to influence physician behaviour in POAs.

Physician and clinical integration among rural hospitals

The pressures for closer alignment between physicians and hospitals in both rural and urban areas are increasing. This study empirically specifies independent dimensions of physician and clinical integration and compares the extent to which such activities are practiced between rural and urban hospitals and among rural hospitals in different organizational and market contexts. Results suggest that both rural and urban hospitals practice physician integration, although each emphasizes different types of strategies. Second, urban hospitals engage in clinical integration with greater frequency than their rural counterparts. Finally, physician integration approaches in rural hospitals are more common among larger rural hospitals, those proximate to urban facilities, those with system affiliations, and those not under public control.

Managed care and processes to integrate physicians/hospitals

This article describes the extent to which hospitals use different integrative processes to assimilate physicians and assesses the extent to which their use is associated with managed care penetration and hospital characteristics. Results from a national survey of 1,495 community hospitals indicate that these integrative processes are quite prevalent. The use of integrative processes tends to be more prevalent in hospitals that are large, urban, involved in teaching, and members of hospitals systems. Use of particular integrative processes also appears to be associated with different thresholds of managed care penetration.