Quality of Care Not Affected by Hospital Changes in Physician Employment

More hospitals are switching to employment-based affiliations with physicians, but a recent analysis found no association between conversion to an employment model and changes in mortality, readmissions, length of stay, or patient satisfaction rates.

According to a recent study published in the Annals of Internal Medicine, proportion of hospitals that reported having employment arrangements with physicians rose from 29% in 2003 to 42% in 2012, while the proportion of hospitals reporting unaffiliated or contractual relationships decreased significantly over this time. Beginning in 2009, employment has been the most common hospital—physician affiliation model.

The rationale behind this type of arrangement is that increased hospital—physician integration resulting from employment relationships “will lead to greater care coordination, more closely aligned incentives, and ultimately better patient care.” Previous research has found associations between hospital–physician employment relationships and higher spending and prices, but the Annals study aimed to investigate the characteristics of hospitals that had switched to employment affiliations and the impact of these changes on patient care.

Analysis of hospital characteristics found that the 803 switching hospitals were more likely to be larger and teaching hospitals than hospitals in the same region that had not switched to an employment arrangement with their physicians. Proportions of Medicare and Medicaid patients and rural-urban location distributions were roughly the same among switching and non-switching hospitals.

When comparing performance on measures of patient mortality, readmissions, length of stay, and patient satisfaction, the researchers found little difference between longitudinal trends for the switching hospitals and their matched non-switching counterparts. For instance, comparison of mortality rates 2 years before and 2 years after the conversion found that the change in mortality was —0.4% for switchers and –0.5% for non-switchers. For the other 3 outcome measures, the authors likewise “detected no effect of switching to an employment model on any of our quality metrics, including risk-adjusted readmission rates, length of stay, and patient satisfaction.”

Generally, any changes in condition-specific outcomes showed no difference between switchers and controls. The only statistically significant exception was for the changes in rates of pneumonia readmission. The hospitals that had switched to employment models showed a marginally greater decrease in this measure than the hospitals that had not switched.

The authors acknowledged that more research must be done to determine the role that hospital—physician employment relationships can play in increasing the efficiency and quality of care, but these improvements cannot be achieved through employment affiliations alone.

“Although some of these improvements certainly are taking place as hospitals increasingly employ physicians,” they wrote, “on the basis of the hospital performance metrics we examined, we found no national-level evidence that these changes have translated into better patient care.”

They concluded with a recommendation that hospitals should focus on meaningful ways to boost clinical integration and improve patient care instead of hoping that these goals will be accomplished solely by employing more physicians.