Division of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN.
Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN; Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN.
J Am Coll Surg. 2020 Jan;230(1):130-135.e4. doi: 10.1016/j.jamcollsurg.2019.09.016. Epub 2019 Oct 28.
Vertical integration is increasingly common among surgical specialties in the US; however, the effect of vertical integration on access to care for low-income populations remains poorly understood. We explored the characteristics of surgical practices associated with vertical integration and the effect of integration on surgical access for Medicaid populations.
Using a survey of US office-based physician practices, we examined characteristics of 15 surgical subspecialties from 2007 to 2017, including provider sex and specialty, practice payer mix, surgical volume, and county socioeconomic status. Using multivariable logistic regression and time-series analysis, we evaluated practice and provider characteristics associated with vertical integration-our primary outcome-and practice Medicaid acceptance rates-our secondary outcome.
Our analysis included 84,795 unique surgical practices (303,903 practice-years). The rate of vertical integration during the 10-year period was 18.0%, with 72.1% of surgical practices never integrating. Practices that integrated were more likely to accept Medicaid patients than practices that did not (81.0% vs 60.8%, p < 0.001). Accepting Medicaid increased the likelihood of vertical integration relative to practices that did not (odds ratio [OR] 4.20, 95% CI 3.93 to 4.49). Practices that integrated were more likely to accept Medicaid in the future (OR 2.61, 95% CI 2.40 to 2.83), even after adjusting for previous Medicaid acceptance and hospital and time fixed effects.
Surgical practices caring for the underinsured are more likely to join larger health care systems, driven by market characteristics. Vertical integration is associated with future increased rates of Medicaid acceptance among practices, allowing for increased access to surgical care for vulnerable, low-income patients. The potential benefit of increased surgical access for low-income beneficiaries from vertical integration must be balanced with the potential for increased prices.
在美国，外科专业的纵向整合越来越普遍；然而，纵向整合对低收入人群获得医疗服务的影响仍知之甚少。我们探讨了与纵向整合相关的外科实践特征，以及整合对医疗补助人群获得外科服务的影响。
我们使用对美国基于办公室的医生实践的调查，研究了 2007 年至 2017 年 15 个外科亚专业的特征，包括提供者的性别和专业、实践支付者组合、手术量和县社会经济地位。我们使用多变量逻辑回归和时间序列分析，评估了与纵向整合（我们的主要结果）和实践 Medicaid 接受率（我们的次要结果）相关的实践和提供者特征。
我们的分析包括 84795 个独特的外科实践（303903 个实践年）。在 10 年期间，纵向整合的比例为 18.0%，72.1%的外科实践从未整合过。与未整合的实践相比，整合的实践更有可能接受医疗补助患者（81.0%对 60.8%，p < 0.001）。与未接受 Medicaid 的实践相比，接受 Medicaid 增加了纵向整合的可能性（优势比[OR]4.20，95%置信区间[CI]3.93 至 4.49）。整合的实践更有可能在未来接受 Medicaid（OR 2.61，95% CI 2.40 至 2.83），即使在调整了之前的 Medicaid 接受情况和医院和时间固定效应之后也是如此。
为保险不足的人提供护理的外科实践更有可能加入更大的医疗保健系统，这是由市场特征驱动的。纵向整合与实践中未来 Medicaid 接受率的增加相关，这为弱势、低收入患者获得外科护理提供了更多机会。从纵向整合中增加低收入受益人的外科获得量的潜在好处必须与价格上涨的潜在风险相平衡。
