PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts.
Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
JAMA Health Forum. 2024 Aug 2;5(8):e242173. doi: 10.1001/jamahealthforum.2024.2173.
Vertical relationships (ownership, affiliations, joint contracting) between physicians and health systems are increasing in the US. Many proponents of vertical relationships argue that increased spending associated with consolidation is accompanied by improvements in quality of care.
To assess the association of vertical relationships between primary care physicians (PCPs) and large health systems and quality of care.
DESIGN, SETTING, AND PARTICIPANTS: This stacked difference-in-differences study compared outcomes for patients whose attributed PCP entered a vertical relationship with a large system in 2015 or 2017 to patients whose PCP was either never or always in a vertical relationship with a large system from 2013 to 2017. Models account for differences between PCPs, patient characteristics, market concentration, and secular trends. Data were derived from the 2013 to 2017 Massachusetts All-Payer Claims Database. The study population included commercially insured individuals attributed to a PCP in the Massachusetts Health Quality Partners' Massachusetts Provider Database in 2013, 2015, or 2017. Analyses were conducted between January 2021 and January 2024.
PCPs attributed to patients in the study entering a vertical relationship with a large health system in 2015 or 2017.
Low-value care utilization, posthospitalization follow-up, utilization among patients with ambulatory care-sensitive conditions, practice site visit fragmentation, and timeliness of specialty care.
The study population included 4 603 172 patient-year observations from 2013 to 2017. Among all patients in the study, 53.5% were female, 35.3% had any chronic condition, and the mean (SD) age was 38.9 (20.3) years. There was no association between vertical relationships and low-value care or ambulatory care-sensitive conditions utilization. A patient's PCP entering a vertical relationship had no association with the probability of follow-up within 90 days of cancer diagnosis with any oncologist but was associated with a 7.34-percentage point (pp) (95% CI, 2.28-12.40; P = .01) increase in the probability of follow-up with an oncologist in the health system. Vertical relationships were associated with increased posthospitalization follow-up with a physician in the health system by 7.51 pp (95% CI, 2.96-12.06: P = .001) in the 2015 subgroup. PCP-health system vertical relationships were associated with a significant decrease in fragmentation of practice site visits of -1.05 pp (95% CI, -2.05 to 0.05; P = .04).
In this study, vertical relationships between PCPs and large health systems were associated with patient steering and changes in care delivery processes, but not necessarily improvements in patient outcomes.
在美国，医生和医疗系统之间的垂直关系（所有权、附属关系、联合承包）正在增加。许多垂直关系的支持者认为，与合并相关的支出增加伴随着医疗质量的提高。
评估初级保健医生 (PCP) 与大型医疗系统之间垂直关系与护理质量之间的关联。
设计、设置和参与者：这项堆叠差异中的差异研究将在 2015 年或 2017 年与大型系统建立垂直关系的患者的结果与 2013 年至 2017 年期间从未或始终与大型系统建立垂直关系的患者的结果进行比较。模型考虑了 PCP 之间、患者特征、市场集中度和长期趋势的差异。数据来自 2013 年至 2017 年马萨诸塞州全支付者索赔数据库。研究人群包括在马萨诸塞州医疗质量合作伙伴的马萨诸塞州提供者数据库中 2013 年、2015 年或 2017 年归因于 PCP 的商业投保个体。分析于 2021 年 1 月至 2024 年 1 月进行。
归因于研究中患者与大型医疗系统建立垂直关系的 PCP。
低价值护理利用率、出院后随访、门诊护理敏感条件利用率、实践地点就诊碎片化以及专科护理的及时性。
研究人群包括 2013 年至 2017 年期间的 4603172 个患者年观察结果。在研究中的所有患者中，53.5%为女性，35.3%有任何慢性疾病，平均（SD）年龄为 38.9（20.3）岁。垂直关系与低价值护理或门诊护理敏感条件利用率之间没有关联。患者的 PCP 与任何肿瘤医生的 90 天内随访的概率没有关联，但与在健康系统中与肿瘤医生随访的概率增加 7.34 个百分点（95%CI，2.28-12.40；P = .01）相关。垂直关系与健康系统内医生的出院后随访增加 7.51 个百分点（95%CI，2.96-12.06：P = .001）有关，这在 2015 年亚组中是相关的。PCP-健康系统垂直关系与实践地点就诊碎片化显著降低有关，降低了 1.05 个百分点（95%CI，-2.05 至 0.05；P = .04）。
在这项研究中，PCP 与大型医疗系统之间的垂直关系与患者引导和护理提供过程的变化有关，但不一定与患者结果的改善有关。
