Department of Health Policy and Management, Harvard Chan School of Public Health, Boston, Massachusetts.
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Netw Open. 2021 Apr 1;4(4):e216848. doi: 10.1001/jamanetworkopen.2021.6848.
As health care delivery markets have changed and new payment models have emerged, physicians in many specialties have consolidated their practices, but whether this consolidation has occurred in surgical practices is unknown.
To examine changes in the size of surgical practices, market-level factors associated with this consolidation, and how place of service for surgical care delivery varies by practice size.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of Medicare Data on Provider Practice and Specialty from January 1 to December 31, 2013, compared with January 1 to December 31, 2017, was conducted on all general surgeon practices caring for patients enrolled in Medicare in the US. Data analysis was performed from November 4, 2019, to January 9, 2020.
Practice sizes in 2013 and 2017 were compared relative to hospital market concentration measured by the Herfindahl-Hirschman Index in the hospital referral region.
The primary outcome was the change in size of surgical practices over the study period. Secondary outcomes included change in surgical practice market concentration and the place of service for provision of surgical care stratified by surgical practice size.
From 2013 to 2017, the number of surgical practices in the US decreased from 10 432 to 8451. The proportion of surgeons decreased in practices with 1 (from 26.2% to 17.4%), 2 (from 8.3% to 6.6%), and 3 to 5 (from 18.0% to 16.5%) surgeons, and the proportion of surgeons in practices with 6 or more surgeons increased (from 47.6% to 59.5%). Hospital concentration was associated with an increase in the size of the surgical practice. Each 10% increase in the hospital market concentration was associated with an increase of 0.204 surgeons (95% CI, 0.020-0.388 surgeons; P = .03) per practice from 2013 to 2017. Similarly, a 10% increase in the hospital-level HHI was associated with an increase in the surgical practice HHI of 0.023 (95% CI, 0.013-0.033; P < .001). Large surgical practices increased their share of Medicare services provided from 36.5% in 2013 to 45.6% in 2017. Large practices (31.3% inpatient in 2013 to 33.1% in 2017) were much more likely than small practices (19.0% inpatient in 2013 to 17.7% in 2017) to be based in hospital settings and this gap widened over time.
Surgeons have increasingly joined larger practices over time, and there has been a significant decrease in solo, small, and midsize surgical practices. The consolidation of surgeons into larger practices appears to be associated with hospital market concentration in the same market. Although overall care appears to be more hospital based for larger practices, the association between the consolidation of surgical practices and patient access and outcomes should be studied.
随着医疗保健服务市场的变化和新的支付模式的出现，许多专业的医生已经整合了他们的实践，但这种整合是否发生在外科实践中尚不清楚。
研究外科实践规模的变化、与这种整合相关的市场因素，以及手术服务提供的服务地点如何因实践规模而异。
设计、地点和参与者：一项横断面研究比较了 2013 年 1 月 1 日至 12 月 31 日和 2017 年 1 月 1 日至 12 月 31 日期间美国所有接受 Medicare 患者的普通外科医生实践的数据，该研究基于 Provider Practice 和 Specialty 的 Medicare 数据。数据分析于 2019 年 11 月 4 日至 2020 年 1 月 9 日进行。
比较了 2013 年和 2017 年的实践规模，相对于医院参考区域的赫芬达尔-赫希曼指数（Herfindahl-Hirschman Index）衡量的医院市场集中程度。
主要结果是研究期间外科实践规模的变化。次要结果包括外科实践市场集中程度的变化以及按外科实践规模分层的外科护理提供地点的变化。
从 2013 年到 2017 年，美国的外科实践数量从 10432 个减少到 8451 个。在有 1 名（从 26.2%降至 17.4%）、2 名（从 8.3%降至 6.6%）和 3 至 5 名（从 18.0%降至 16.5%）外科医生的实践中，外科医生的比例下降，而在有 6 名或更多外科医生的实践中，外科医生的比例增加（从 47.6%增加到 59.5%）。医院集中与外科实践规模的增加有关。医院市场集中每增加 10%，与 2013 年至 2017 年期间每实践增加 0.204 名外科医生（95%置信区间，0.020-0.388 名外科医生；P = .03）相关。同样，医院级别的 HHI 每增加 10%，与外科实践 HHI 增加 0.023（95%置信区间，0.013-0.033；P < .001）相关。大型外科实践将其提供的 Medicare 服务份额从 2013 年的 36.5%增加到 2017 年的 45.6%。大型实践（2013 年住院患者 31.3%至 2017 年住院患者 33.1%）比小型实践（2013 年住院患者 19.0%至 2017 年住院患者 17.7%）更有可能基于医院环境，而且这种差距随着时间的推移而扩大。
随着时间的推移，外科医生越来越多地加入更大的实践，而单独、小型和中型的外科实践数量显著减少。外科医生向更大实践的整合似乎与同一市场中的医院市场集中有关。尽管总体护理似乎更以医院为基础，但应该研究外科实践整合与患者获得和结果之间的关系。
