Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
Harvard PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts.
JAMA Health Forum. 2023 Sep 1;4(9):e232875. doi: 10.1001/jamahealthforum.2023.2875.
Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US.
To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals.
DESIGN, SETTING, AND PARTICIPANTS: This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023.
Evaluation-and-management visit with attributed PCP in 2015 to 2017.
Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate).
The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes.
Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.
重要性：在美国，医生和医疗系统之间的垂直关系（例如，所有权或附属关系，包括联合承包）正在增加。
目的：分析初级保健医生（PCP）与大型医疗系统之间的垂直关系如何与商业保险个人的门诊和急性护理利用、转诊模式、再入院和总医疗支出的变化相关。
设计、地点和参与者：这项病例对照研究采用重复横截面、堆叠事件设计，分析了 2015 年或 2017 年与大型医疗保健系统建立垂直关系的 PCP 的患者的结果，与 2013 年至 2017 年期间 PCP 与大型医疗系统始终或从未建立垂直关系的患者相比。样本包括符合入组标准且在 2013 年、2015 年和 2017 年被纳入马萨诸塞州提供者数据库的商业保险患者，并且测量了垂直关系。入组者和索赔数据来自 2013 年至 2017 年马萨诸塞州全支付索赔数据库。统计分析于 2021 年 1 月 5 日至 2023 年 6 月 5 日之间进行。
暴露：2015 年至 2017 年期间与 PCP 的评估和管理就诊。
主要结果和措施：在该样本中，每个患者年（即从 1 月至 12 月每个患者每年）测量的结果包括利用（专科医生就诊、急诊就诊和住院的总数以及在归因于 PCP 的医疗系统内）、支出（总医疗支出和高价格医院的使用）和再入院率（再入院率和低再入院率医院的使用）。
结果：该样本包括 4030224 次观察，其中包括 2147303 名女性（53.3%）和 1881921 名男性（46.7%），平均（SD）年龄为 35.07（19.95）岁。PCP 和大型医疗系统之间的垂直关系与专科就诊次数的增加相关，每患者年增加 0.69（95%CI，0.34-1.04；P<0.001），与对照组平均值相比增加了 3.06 次就诊，每患者年的总医疗支出增加了 356.67 美元（95%CI，77.16-636.18 美元；P=0.01），与对照组平均值相比增加了 6.26%，达到 5700.07 美元。在归因于 PCP 的医疗保健系统内，专科就诊次数每患者年增加 0.80（95%CI，0.56-1.05）（P<0.001），与对照组平均值相比增加了 29.38%，为 2.73 次专科就诊。就诊次数每患者年增加 0.02（95%CI，0.01-0.03）（P=0.001），与对照组平均值相比增加了 14.19%，为 0.15 次就诊。就诊次数每患者年增加 0.01（95%CI，0.00-0.01）（P<0.001），与对照组平均值相比增加了 22.36%，为 0.03 次就诊。在再入院结果方面没有差异。
结论：这项病例对照研究的结果表明，PCP 与大型医疗系统之间的垂直关系与患者转向医疗系统和增加患者护理支出有关，但未发现再入院率的差异。
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