Abstract
Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Greater APM participation appears to be supported by integration and system ownership.
Highlights
Covariateadjusted analyses suggested that operating within a health care system, greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater alternative payment models (APMs) participation
After adjusting for sampling weights accounting for National Survey of Healthcare Organizations and Systems (NSHOS) complex survey design, 1876 of 2061 physician practices (91.0% [after adjusting for sampling weights]) reported participating in at least 1 APM and 1153 of all practices (49.2%) participated in 3 or more models simultaneously (Figure 1)
When examining practice participation rates by individual alternative payment model category, we still found that pay-for-performance (1384 [64.0% after adjusting for sampling weights]) and accountable care organizations (ACOs)
Summary
Since the Patient Protection and Affordable Care Act was passed in 2010, the shift toward valuebased payment has promised to reward potential efficiency and quality improvements that may result from integrating care across health care professionals.[1,2] Despite the expansion of value-based payment models offered by public and private payers, participation in alternative payment models (APMs) may vary[3] depending on organizational characteristics and structure or geographic area.[4,5,6,7] There is some evidence that higher levels of integration are associated with a more efficient delivery system[8] and that integrated medical groups provide better health care quality than independent practices.[9]. We hypothesized that each of these types of integration may accelerate adoption of APMs
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