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Increasing employment of physicians in hospitals not associated with improved quality of care

Over the past decade, the percentage of hospitals that employ physicians increased by 13%, according to data published in the Annals of Internal Medicine.

Kristin W. Scott, MPhil, PhD, from Harvard Medical School, and colleagues reported that this increase did not correspond with significant advances in hospital care.

"Many U.S. policymakers believe that increased integration between hospitals and physicians may foster better care and potentially decrease health care spending," Scott and colleagues wrote. "The logic behind this notion is straightforward: When physicians are employed or otherwise more substantially influenced by the hospitals in which they work, they are less likely to focus on generating revenue to maintain an independent practice and more likely to focus on patient care. Further, as hospitals respond to external pressures to improve quality, the presence of a physician workforce that is tightly integrated with the hospital will make it easier to incentivize clinicians to focus on quality metrics, share common information systems, and comply with clinical guidelines."

The researchers noted that health care executives and policymakers have been moving toward increased integration of physicians and hospitals, despite a history of separation; however, whether this changing relationship has led to better outcomes is still not certain.

"Given the salience of this topic, we sought to examine three key questions: First, what proportion of acute care hospitals in the United States report having an employment relationship with their physicians, and how much has that changed during the past decade?" the researchers asked. "Second, what types of hospitals have chosen to enter into these tight employment relationships with physicians during the past decade, and how do these institutions differ from those that have not? Third, what is the clinical consequence of such a switch on the quality and efficiency of patient care at the hospital level?"

Scott and colleagues conducted a retrospective cohort study of 2,888 nonfederal acute care hospitals in the United States. They used data from American Hospital Association surveys, the Medicare Provider Analysis and Review File (MedPAR), Hospital Compare and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

They measured four outcomes: hospital-level risk-adjusted mortality rates, 30-day readmission rates, risk-adjusted lengths of stay and patient satisfaction scores for three common medical conditions — acute myocardial infarction, congestive heart failure and pneumonia.

Results showed that 29% of hospitals employed physicians in 2003, compared with 42% of hospitals employed in 2012. Hospitals that switched to an employment-type arrangement during this period were more likely to be a major teaching hospital (7.5% vs. 4.5%) or large (11.6% vs. 7.1%) as well as less likely to be a for-profit institution (8.8% vs. 19.9%) compared with regionally-matched controls (P < .001).

The researchers reported no association between improvement in quality metrics and switching to an employment model.

"During the past decade, an important shift has occurred in the relationship between U.S. hospitals and physicians," Scott and colleagues concluded. "Indeed, for the first time in recent history, U.S. hospitals are more likely to employ physicians than to enter into any other kind of affiliation or relationship with them. This trend, remarkable as it is, likely will increase in the absence of antitrust legal or regulatory challenges."

They continued: "Although many advocates have suggested that hospital employment of physicians likely will result in much better care, we have found no substantive evidence to date to support this notion. As hospital systems continue to acquire physician practices and employ physicians, a focus on true clinical integration, as well as a renewed focus on improving the quality of patient care and clinical outcomes, will be essential." – by Chelsea Frajerman Pardes

Disclosure: Please see the full study for a complete list of all authors' relevant financial disclosures.