Howard S. Zuckerman

Implementing evidence-based medicine: The role of market pressures, compensation incentives, and culture in physician organizations

Objectives.To assess the extent to which market pressures, compensation incentives, and physician medical group culture are associated with the use of evidence-based medicine practices in physician organizations. Methods.Cross-sectional exploratory study of 56 medical groups affiliated with 15 integrated health systems from across the United States, involving 1,797 physician respondents. Larger medical groups and multispecialty groups were overrepresented compared with the United States as a whole. Data are from two sources: (1) surveys of physicians assessing the culture of the medical groups in which they work, and (2) surveys of medical directors and other managerial key informants pertaining to care management practices, compensation methods, and the management and governance of the medical groups. Physician-level data were aggregated to the group level to attain measures of group culture and then merged with the data regarding care management, incentives, and management and governance. Stepwise multiple regression was used to examine the study hypotheses. Results.As hypothesized, the number of different types of compensation incentives used (cost containment, productivity, quality) was positively associated with the comprehensiveness of care management practices. The degree of salary control (ie, market-based salary grades and ranges versus the use of bookings or fees and individual negotiation) was also positively associated with the deployment of care management practices. As hypothesized, market pressures in the form of percentages of health maintenance and preferred provider organization patients seen were generally positively associated with the use of care management practices. Organizational culture had no association except that a patient-centered culture in combination with a greater number of different types of compensation incentives used was positively associated with greater use of care management practices. Conclusions.Both compensation incentives and managed care market pressures were significantly associated with the use of evidence-based care management practices. The lack of association for culture may be due to the relatively amorphous nature of most physician organizations at this point.

Hospital alliances: cooperative strategy in a competitive environment.

The resource dependence perspective is used to describe the formation of hospital alliances. Characteristics of alliances and their various strategies and structures are discussed. A life cycle model provides a framework for viewing the development and growth of alliances. Several dimensions for assessing alliance performance are proposed.

Just how integrated are integrated delivery systems? Results from a national survey.

This article examines three emergent processes in physician-hospital integrated delivery systems (IDSs). We find these processes are underdeveloped based on data gathered from a national sample of hospitals drawn from nine health care systems. These processes are also loosely coupled with the structures used to integrate physicians and hospitals, as well as with the environmental context in which they occur. Such loose coupling entails both advantages and disadvantages for IDSs.

Physician-System Relationships Stumbling Blocks and Promising Practices

Objectives.To identify the barriers, facilitators, and potential better practices to achieving physician-system alignment. Methods.Interviews using a semi-structured, open-ended protocol were conducted during a total of 18 site visits, each usually 2 days in length, covering multiple topics of physician group-system alignment. Interviews were conducted with members of the target physician group, key leaders of the health care system, and representatives of physicians not in the target group. The summary of the interviews for each of the site visits was analyzed to determine barriers, facilitators, and better practices for achieving more effective relationships between physician groups and health care systems. Results.A number of barriers to more effective relationships between physician groups and health systems were identified. Barriers related to environment, culture, and information systems were most prevalent. Other major general areas of barriers encountered were physician leadership, group-system relationship, compensation and productivity, care management practices, group strategy, and accountability. Examples of practices that may help to resolve some of these issues were also identified. Conclusions.Physician-system relationships can and do cause problems for improving health care. The evidence from the conducted site visits suggests that specific strategies may help improve these relationships but more research is needed in order assess the actual impact of these strategies.

Strategies for effective management participation in community health partnerships.

This article develops guidelines for effective health services management participation in community health partnerships. Drawing on our study of Community Care Network (CCN) Demonstration, the strategic alliance literature, and other research, we describe six challenges that health services managers are likely to face as partnership participants and discuss the strategies that they might use to deal with them.

Physicians and organizations: strange bedfellows or a marriage made in heaven?

Summary Underscoring the importance of physician‐organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested.

The challenges of governing integrated health care systems.

As health care delivery organizations develop into integrated health care systems, new and significant challenges arise with respect to how such systems should be governed. This article explores several key governance issues that organizations are likely to encounter as they attempt to effect the transition from hospital or multihospital system governance arrangements to those appropriate for integrated systems.

Organizational Approaches to Integrated Health Care Delivery: A Taxonomic Analysis of Physician-Organization Arrangements

Integrated health care organizations depend fundamentally on bringing organizations and physicians into closer alignment. Little empirical research has been conducted on the organizational mechanisms by which such alignment is attempted. This study employed primary data from 79 hospitals and health care systems to identify current approaches to aligning the strategic and economic interests of organizations and physicians. An empirical classification of both unbundled and structured physician-organization arrangements (POAs) resulted in 5 distinct strategic configurations. These configurations were differentiated by key contextual factors that shape patterns of development and operation of POAs. Particularly salient among these were managed care penetration, organization size, locus of control, and organization strategy. Results of the taxonomic analysis underscore the facts that most delivery organizations employ multifaceted rather than single approaches to physician integration and that these approaches are endemic to particular environmental and organizations conditions.

Physician-system alignment: introductory overview.

The papers in this Special Supplement are based on research funded by the participating members of the joint Center for Health Management Research (CHMR) and Center for Organized Delivery Systems (CODS), and supported by the National Science Foundation under its Industry-University Cooperative Research Center Program. This 3-year research initiative from 1996 through 1999 involved 69 physician organizations (primarily organized medical groups as opposed to IPAs) associated with 14 organized delivery systems. The groups ranged in size from three to 958 with an average size of 76.4 and a median size of 25.0. Comparisons of the study groups with United States physician groups overall are shown in Table 1. The study groups are larger and more likely to be multispecialty than all groups in the United States. Table 1. Comparison of PSA Study Groups With US Physician GroupsAdapted from Havlicek PL. Medical Groups in the US, 1999. Chicago: American Medical Association; 1999.†Groups that participated in individual physician-level survey phase of data collection.‡Group that did not participate in individual physician-level survey phase of data collection.The organized delivery systems range in size from one hospital to 80 hospitals with an average of 21 hospitals per system and a median of 11 hospitals per system. They average 4.6 affiliated medical groups with a range from one to 23. The organized delivery systems range in total revenues in 1998 from

Physician commitment to organized delivery systems

340 million to