Tracking the changing provider landscape: implications for health policy and practice.

Throughout the 1990s health care providers were interested in developing organized delivery systems. However, industry observers have increasingly questioned the sense of these efforts. Using an established taxonomy of health networks and systems, we examined whether there was a nationwide trend away from the vertical and horizontal arrangements that serve as the backbone to organized delivery systems.

Keys to building effective community partnerships.

A four-year study of 25 community health partnerships reveals the six characteristics that help partnerships succeed. Managing size and diversity, addressing coalition conflict, and recognizing life cycles are among the primary behaviors differentiating the strong from the weak.

Physician-system relationships: stumbling blocks and promising practices.

Objectives: To identify the barriers, facilitators, and potential better practices to achieving physician-system alignment.

Methods: Interviews using a semi-structured, open-ended protocol were conducted during a total of 18 site visits, each usually 2 days in length, covering multiple topics of physician group-system alignment. Interviews were conducted with members of the target physician group, key leaders of the health care system, and representatives of physicians not in the target group.

Physician commitment to organized delivery systems.

Background: Health care systems have developed many types of contracting vehicles with physicians. The immediate aim of these vehicles has been to foster physician commitment and alignment to the system. The ultimate aim of these vehicles has been to garner managed care contracts, reduce costs, and improve quality.

Factors associated with physician involvement in care management.

Background: Enthusiasm for the concept of care management (CM) has led to unprecedented growth in the number of guidelines and protocols, but provider organizations have struggled to enlist the active support and participation of physicians in CM activities.

Objectives: To empirically examine the factors influencing physician participation in and attitudes toward CM activities.

Methods: Data on 1,514 physicians were used to predict physician attitudes toward CM and their perceptions of group CM behaviors.

Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture in physician organizations.

Objectives: To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations.

Methods: Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole.

Risk assumption and physician alignment with health care organizations.

Objectives: To examine the association between risk assumption by individual physicians and physician groups and the degree of alignment between physicians and health care systems.

Methods: A cross sectional comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians.

The ties that bind: interorganizational linkages and physician-system alignment.

Objectives: To examine the association between the degree of alignment between physicians and health care systems, and interorganizational linkages between physician groups and health care systems.

Methods: The study used a cross sectional, comparative analysis using a sample of 1,279 physicians practicing in loosely affiliated arrangements and 1,781 physicians in 61 groups closely affiliated with 14 vertically integrated health systems. Measures of physician alignment were based on multiitem scales validated in previous studies and derived from surveys sent to individual physicians.

Physician-system alignment: introductory overview.

The papers in this Special Supplement are based on research funded by the participating members of the joint Center for Health Management Research (CHMR) and Center for Organized Delivery Systems (CODS), and supported by the National Science Foundation under its Industry-University Cooperative Research Center Program. This 3-year research initiative from 1996 through 1999 involved 69 physician organizations (primarily organized medical groups as opposed to IPAs) associated with 14 organized delivery systems. The groups ranged in size from three to 958 with an average size of 76.

Improving the quality of health care in the United Kingdom and the United States: a framework for change.

Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level.

The financial performance of hospitals belonging to health networks and systems.

The U.S. health industry is experiencing substantial restructuring through ownership consolidation and development of new forms of interorganizational relationships.

Classifying health networks and systems: managerial and policy implications.

This article illustrates how a new approach to classifying health networks and systems can be used to evaluate the readiness of health care organizations to accept risk. Examples are provided from the Harris-Methodist, Henry Ford, and SSM Health Care Systems. The classification system can also be used to assist executives and physician leaders in making decisions involving the centralization of services, the number of different services to offer, and decisions to enter into various strategic alliances.

The governance and management of effective community health partnerships: a typology for research, policy, and practice.

Community health partnerships (CHPs) are voluntary collaborations of diverse community organizations that have joined forces in order to pursue a shared interest in improving community health. Although these cross-sectoral collaborations represent a way to address social determinants of health and disease in society, they suffer from governance and management problems associated with interorganizational relationships in general and health care challenges specifically. A typology of effective governance and management characteristics provides a systematic, theoretically based way of addressing dimensions of governance and management and serves as a guide in constructing, maintaining, and measuring successful partnerships.

Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.

Objectives: To assess the impact of total quality management (TQM) and organizational culture on a comprehensive set of endpoints of care for coronary artery bypass graft surgery (CABG) patients, including risk-adjusted adverse outcomes, clinical efficiency, patient satisfaction, functional health status, and cost of care.

Methods: Prospective cohort study of 3,045 eligible CABG patients from 16 hospitals using risk-adjusted clinical outcomes, functional health status, patient satisfaction, and cost measures. Implementation of TQM was measured by a previously validated instrument based on the Baldridge national quality award criteria.

The cost of efforts to improve quality.

Background: Virtually all hospitals in the United States report that they engage in efforts to improve quality, such as continuous quality improvement (CQI). Little is known about the costs of these efforts and whether they are associated with improved outcomes or lower patient-care costs.

Objectives: The principal objective of this study was to provide benchmark data on the costs of efforts to improve quality.

Best practices in managing organized delivery systems.

The U.S. Department of Veterans Affairs (VA), a large public-sector healthcare delivery system, is following the lead of the private sector in seeking a more integrated approach to providing patient care.

A taxonomy of health networks and systems: bringing order out of chaos.

Objective: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features.

Data Sources: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems.

Study Design: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations.

Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress.

The literature on continuous quality improvement (CQI) has produced some evidence, based on nonrandomized studies, that its clinical application can improve outcomes of care while reducing costs. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, and a supportive organizational culture. The few randomized studies, however, suggest no impact of CQI on clinical outcomes and no evidence to date of organization-wide improvement in clinical performance.