Physician Employment by Hospitals Does Not Improve Quality

Marcia Frellick

September 19, 2016

The percentage of hospitals hiring physicians climbed from 29% in 2003 to 42% in 2012, but physician employment alone probably won't improve hospital care, authors of a new study suggest.

Kirstin W. Scott, MPhil, a PhD student in health policy at Harvard University in Cambridge, Massachusetts, and colleagues, published their findings online September 19 in Annals of Internal Medicine.

The researchers looked at mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions for 803 hospitals that switched to the employment model compared with 2085 control hospitals that did not switch.

They found no association between switching to the employment model and improved outcomes in any of the quality metrics examined.

Two years after switching, the estimated change in mortality, for instance, was –0.41% (95% confidence intervaI [CI], –0.75% to –0.08%) among switchers and –0.52% (95% CI, –0.65% to –0.39%) for nonswitchers).

Hospitals that transitioned to this integrated relationship were more likely to be large hospitals (11.6% vs 7.1%) or major teaching hospitals (7.5% vs 4.5%) and less likely to be for-profit institutions (8.8% vs 19.9%) (all P values were <.001).

The only statistically significant quality difference was in pneumonia readmissions. Switchers had a slightly greater decrease than nonswitchers in readmissions for pneumonia, although the change was minimal. The change in the readmission rate for pneumonia was –1.35% (95% CI, –1.81% to –0.88%) for hospitals that switched and –0.75% (95% CI, –0.93% to –0.57%), for a difference in change of –0.60 percentage points (95% CI, –1.1 to 0.0 percentage points).

"Our study, which used contemporary national data, suggests that a fundamental improvement in care delivery will require more than mere changes in hospital–physician integration, and if physician employment is a key ingredient, it must be linked to other key goals, such as hospital prioritization of quality, to be successful," the authors write.

Richard Gunderman, MD, PhD, Chancellor's Professor of radiology, pediatrics, medical education, philosophy, liberal arts, philanthropy, and medical humanities and health studies at Indiana University in Indianapolis, agrees.

He told Medscape Medical News that those who think quality comes from increasingly larger organizations with more advanced information technology and greater standardization across the system will see these results as surprising and disappointing.

But those who see quality as grounded in relationships between healthcare professionals and their patients will not be surprised, he said. Pointing to high levels of burnout and widespread complaints of lack of time with patients, Dr Gunderman said less physician control over individual patient care has taken a toll.

When larger organizations develop standards and protocols and assign blame to doctors for spending too much time with a patient, or ordering or not ordering a particular test, discouragement grows for doctors who have known some patients for years and see themselves as the authority on what's best for them, he added.

"There's no doubt that a demoralized workforce will tend to drive quality down," he said. "Many hospitals and health systems around the country are grappling with poor and, in some cases, dismal engagement scores. I think that's an indication that a lot of physicians feel that the changes taking place across healthcare are problematic."

As hospitals grow, it gets harder for them to rely on personal relationships between healthcare providers and patients as the driver of quality care, he said.

Dr Gunderman predicted that over the next decade, "We will learn that if healthcare organizations are going to be very big, they need to devise new means of thinking and acting as though they're smaller.

"They may still be able to realize some of the advantages of economies of scale…but they will need to figure out ways to enable physicians and other health professionals to work day to day as though they are operating in a smaller organization where the insights, the experience, and the judgment of health professionals are accorded a higher degree of respect" and a more substantial role in the decisions of individual patient care.

The authors acknowledge that the population tested was older (primarily Medicare beneficiaries aged 65 years and older), and therefore the applicability of the findings to a younger population is unclear.

However, they said, they doubted that after switching to an employment model, hospitals would improve care for one group and not another.

The study was funded by the Agency for Healthcare Research and Quality and the National Science Foundation. Coauthors report support from the National Institutes of Health (NIH) during the conduct of the study; non-financial support from Alliance for Aging Research; Demos: A Network for Ideas and Action; University of Arizona; University of Missouri–Kansas City; Intermountain Healthcare; Kaiser Permanente; Journal of the American Medical Association; the US Senate; Partners Healthcare; Princeton University; New Jersey Association of Mental Health and Addiction Agencies; Spinemark; US Department of Health and Human Services; the Advanced Medical Technology Association; Health Policy Commission (Commonwealth of Massachusetts); University of Chicago; Health Affairs; DuPont Children's Hospital; Symposium on US Sustainable Health; National Bureau of Economic Research; Institute of Medicine; Georgia State University; the Federal Reserve Bank Atlanta; The Commonwealth Fund; and Brookings Institute, outside the submitted work; personal fees from Healthcare Financial Management Association; New York City Health and Hospitals Corporation; Robert W. Baird & Co; and Bank of America Webinar, outside the submitted work; and personal fees and nonfinancial support from Novartis Princeton; MedForce; Veterans Health Administration; International Monetary Fund; National Council and Community Behavioral Healthcare; Delaware Health Sciences Alliance; Dartmouth College; Healthcare Billing and Management Association; Cadence Health; Pompeu Fabra University; Aon Hewitt; American Health Lawyers Association; Parenteral Drug Association; UBS; Aetna; Toshiba; Ernst and Young; Yale University; and New York University, outside the submitted work. Dr Gunderman has disclosed no relevant financial relationships.

Ann Intern Med. Published online September 19, 2016. Abstract

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