Introduction

The integration of physicians with hospitals and health systems has surged over the past decade. Between 2012 and 2022, the percentage of physicians in the US in private practice dropped from 60% to 47%, while those employed by or contracted with hospitals or health systems increased from 29% to 41%. This trend raises concerns about higher prices due to the increased negotiating power physicians gain through their affiliations. However, the impact on healthcare quality remains debated. This article examines the effects of physician-hospital integration, particularly focusing on primary care physicians (PCPs) and their access to expanded resources.

The Shift Towards Vertical Relationships

Vertical relationships between physicians and health systems can potentially enhance care coordination, reduce redundant services, and improve access to specialists. This is crucial for managing chronic diseases and preventing unnecessary hospital admissions or emergency department (ED) visits. Integrated systems may also facilitate better post-hospitalisation follow-ups and timely specialist visits.

However, empirical studies reveal mixed outcomes. Some research indicates that these relationships lead to higher spending due to increased prices. Others suggest improvements in cancer screening rates and appropriate ED use. Nevertheless, the overall impact on patient outcomes, such as readmissions or mortality, remains inconclusive.

Research Strategy and Techniques

A difference-in-differences study was conducted to assess the association between PCP-health system vertical relationships and various quality of care measures. The study compared outcomes for patients whose PCPs entered vertical relationships with large systems in 2015 or 2017 against those whose PCPs were either never or always in such relationships from 2013 to 2017. Data were sourced from the Massachusetts All-Payer Claims Database (2013-2017), focusing on commercially insured individuals.

Quality of Care Metrics

The study found no significant changes in low-value care utilisation, ambulatory care-sensitive condition (ACSC) inpatient admissions, or ACSC ED visits. However, there were small improvements in care timeliness and continuity. Specifically, outpatient follow-ups after hospitalisation did not change, but within-system follow-ups increased slightly for three years post-integration.

Practice Site Fragmentation

Vertical relationships were associated with decreased practice site fragmentation and increased within-system oncology follow-ups. While this may improve patient experiences, it also suggests patient steering, leading to higher spending due to increased prices. This aligns with previous studies showing no quality improvement but higher costs and intensive service use.

Revenue-Generating Incentives

The study highlights the influence of fee-for-service payment models on consolidation outcomes. Low-value care services remain revenue-generating, and the lack of change in these services could be attributed to unchanged financial incentives. Health systems with hospitals are not penalised for admissions or ED visits unless part of contracts discouraging avoidable utilisation. This may explain the observed patterns in within-system follow-ups and practice site fragmentation.

Implications for Policymakers

The findings suggest that vertical relationships between PCPs and health systems do not necessarily improve care quality but may increase costs. Policymakers and antitrust regulators should consider these outcomes when evaluating the benefits and drawbacks of healthcare consolidation. The potential for increased spending without corresponding quality improvements warrants careful consideration in policy decisions.

Conclusion

In Massachusetts, vertical relationships between PCPs and large health systems showed no significant impact on low-value care, hospital admissions, or ED visits for ACSCs among commercially insured individuals. While there were small reductions in care fragmentation and increases in within-system follow-ups, these changes suggest patient steering rather than quality improvements. Policymakers must weigh these findings against the demonstrated cost increases when considering healthcare consolidation strategies.