Association of Financial Integration Between Physicians and Hospitals With Commercial Health Care Prices
Association of Financial Integration Between Physicians and Hospitals With Commercial Health Care Prices
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DOI：
10.1001/jamainternmed.2015.4610
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发表时间：
2015-12-01
影响因子：
39
通讯作者：
McWilliams, J. Michael
中科院分区：
文献类型：
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作者：
Neprash, Hannah T.;Chernew, Michael E.;McWilliams, J. Michael
重要性 医生和医院之间的财务一体化可能有助于医疗保健提供者组织应对新支付模式的挑战，但也可能增强提供者组织的议价能力，从而导致商业医疗保健市场的价格和支出上涨。 目的 评估近期医生-医院一体化的增加与门诊和住院服务支出和价格变化之间的关联。 设计、设置和参与者 使用回归分析，我们估计了自 1 月 1 日起医生-医院一体化变化之间的关系， 2008 年至 2012 年 12 月 31 日，240 个大都市统计区 (MSA) 的支出情况及同期变化。针对患者、计划和市场特征（包括医生、医院和保险公司的市场集中度）进行了调整。研究人群包括研究期间 Truven Health MarketScan 商业数据库中包含的首选提供商组织或服务点计划的 7 391 335 名非老年参与者。数据分析时间为 2013 年 12 月 1 日至 2015 年 7 月 13 日。 暴露 医生与医院一体化，使用 Medicare 索赔数据衡量，作为 MSA 中对门诊服务开具账单的医生所占的比例，服务地点代码表明医院的雇佣或执业所有权。 主要结果和措施 每个登记者的年度住院和门诊支出以及医疗保健服务的相关使用情况，利用率通过以下方式衡量价格标准化支出（年度服务计数总和乘以服务允许收费的全国平均值）。 结果 在 240 个 MSA 中，从 2008 年到 2012 年，医生与医院的一体化平均增加了 3.3 个百分点，各个 MSA 的增幅差异很大（四分位数间距为 0.8-5.2 个百分点）。对于我们的 7 391 335 名非老年参与者的研究样本来说，医生与医院一体化程度的提高相当于 MSA 所经历变化的第 75 个百分位，与 2008 年至 2012 年每个参与者的年度门诊支出平均增加 75 美元（95% CI，38-113 美元（P < .001））相关，相对于 2012 年的平均门诊支出增加了 3.1%。 2012 年（每位参与者 2407 美元 [95% CI，2400-2414 美元]）。门诊支出的增加几乎完全是由价格上涨驱动的，因为利用率的相关变化很小（价格标准化支出的相应变化，每位参与者 14 美元 [95% CI，-13 美元至 41 美元]；P = 0.32）。医生与医院一体化的变化与住院支出（每位登记者 22 美元 [95% CI，-$1 至 $46]；P = .06）或利用率（每位登记者 10 美元 [95% CI，-$12 至 $31]；P = .37）的显着变化无关。 结论和相关性 医生和医院之间的财务一体化与较高的商业价格和门诊护理支出相关。
IMPORTANCE Financial integration between physicians and hospitals may help health care provider organizations meet the challenges of new payment models but also may enhance the bargaining power of provider organizations, leading to higher prices and spending in commercial health care markets.OBJECTIVE To assess the association between recent increases in physician-hospital integration and changes in spending and prices for outpatient and inpatient services.DESIGN, SETTING, AND PARTICIPANTS Using regression analysis, we estimated the relationship between changes in physician-hospital integration from January 1, 2008, through December 31, 2012, in 240 metropolitan statistical areas (MSAs) and concurrent changes in spending. Adjustments were made for patient, plan, and market characteristics, including physician, hospital, and insurer market concentration. The study population included a cohort of 7 391 335 nonelderly enrollees in preferred-provider organizations or point-of-service plans included in the Truven Health MarketScan Commercial Database during the study period. Data were analyzed from December 1, 2013, through July 13, 2015.EXPOSURE Physician-hospital integration, measured using Medicare claims data as the share of physicians in an MSA who bill for outpatient services with a place-of-service code indicating employment or practice ownership by a hospital.MAIN OUTCOMES AND MEASURES Annual inpatient and outpatient spending per enrollee and associated use of health care services, with utilization measured by price-standardized spending (the sum of annual service counts multiplied by the national mean of allowed charges for the service).RESULTS Among the 240 MSAs, physician-hospital integration increased from 2008 to 2012 by a mean of 3.3 percentage points, with considerable variation in increases across MSAs (interquartile range, 0.8-5.2 percentage points). For our study sample of 7 391 335 nonelderly enrollees, an increase in physician-hospital integration equivalent to the 75th percentile of changes experienced by MSAs was associated with a mean increase of $75 (95% CI, $38-$113) per enrollee in annual outpatient spending (P < .001) from 2008 to 2012, a 3.1% increase relative to mean outpatient spending in 2012 ($2407 [95% CI, $2400-$2414] per enrollee). This increase in outpatient spending was driven almost entirely by price increases because associated changes in utilization were minimal (corresponding change in price-standardized spending, $14 [95% CI, -$13 to $41] per enrollee; P = .32). Changes in physician-hospital integration were not associated with significant changes in inpatient spending ($22 [95% CI, -$1 to $46] per enrollee; P = .06) or utilization ($10 [95% CI, -$12 to $31] per enrollee; P = .37).CONCLUSIONS AND RELEVANCE Financial integration between physicians and hospitals has been associated with higher commercial prices and spending for outpatient care.