A Tale of Two Physician
Organization Ownership Types
Margaret C. Wang
RAND/UCLA Post-Doctoral Fellow
AcademyHealth Annual Research Meeting
6/28/05
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Background
• The “quality chasm” in health
care
• Paradigm shift in chronic care
delivery
• The crucial role of physician
organizations (POs)
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PO Ownership Structures
Why does it matter?
• Freestanding physician-owned
• System-affiliated hospital-owned
“Who owns the equipment and
employs the non-physician staff of
your PO (including MSO, if any)?”
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Research Questions
1. What is the association between the
type of PO ownership structure and:
– Clinical IT, scheduling and follow-up
capabilities, availability of case
managers, and financial resources
– External incentives for quality
2. How does ownership structure affect
the implementation of the Chronic
Care Model?
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The Chronic Care Model (CCM)
Source: Wagner et al., 1999
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The Chronic Care
Management Index (CCMI)
CCM Model Components
CCMI Measures
Community Linkages: Community Service Agencies
Referral Systems
Self-Management Support: Assessment of Patient Self-Management
Use of Programs to Increase Skills
Decision Support: Integration of Guidelines
Integration of Specialist Expertise
Delivery System Design: Planned Visits
Multiple Providers
Use of Case Managers
Clinical Information Systems: Provision of Written Feedback
MDs Use of Internet for Communication
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Data Source
• National Study of Physician
Organizations and the Management
of Chronic Illnesses
– National census of physician organizations
employing 20 or more physicians (2000 –
2001)
– Final sample size = 1,104 (70% response rate)
– 67% medical group and 33% IPAs
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Descriptive Statistics
Physician-Owned POs
N = 561
Hospital-Owned POs
N = 405
Medical Group (%):
58
85
IPA (%):
42
15
Single Specialty (%):
17
7
Primary Care (%):
8
14
Multispecialty (%):
75
79
(N = 519)
(N = 371)
Mean:
22
17
Pacific (%):
24
16
Non-Pacific(%):
76
84
PO Type
Practice Specialty
Risk Assumption for Hospital Costs
Geographic Location
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Organizational Resources
• Mean values for structural and human resources:
Index (Range)
Physician-Owned
Hospital-Owned
Clinical IT Index (0-6)*
1.1
1.7
Group Visit Scheduling Index (0-4)*
0.3
0.7
Multiple Needs Scheduling Index (0-4)*
1.0
1.7
Follow-up Index (0-4)*
0.9
1.5
Case Manager Availability Index (0-4)*
1.1
1.5
• Percentage of POs reporting breaking even vs. loss:
Physician-Owned
Hospital-Owned
Reported Loss*
36
61
Reported Broke Even /Made Profit*
64
39
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Impact of External Incentives
• Mean value for Quality Reporting Requirement Index:
Quality Report. Require. Index (0-4)*
Physician-Owned
Hospital-Owned
0.6
1.0
• Percentage of PO reporting receiving external
incentives for quality:
Physician-Owned
Hospital-Owned
PO Receiving Public Recog. for QI*
22
28
PO Receiving Better Contracts for QI
22
25
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Implementation of the CCM
• Mean and standard deviation for the Chronic Care
Management Index (CCMI):
Physician-Owned
Hospital-Owned
(N = 561)
(N = 405)
3.8
5.1
Chronic Care Manage. Index* (0-11)
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Implementation of the CCM
• Stepwise Multivariate Linear Regression:
Intercept
Hospital Ownership
Model 1
Model 2
Model 3
Model 4
15.06
10.75
16.24
12.42
5.68
3.62
3.99
2.74
Clinical IT Index
1.33
0.87
Group Visit Scheduling Index
2.26
2.13
Multiple Needs Scheduling Index
2.17
1.73
Follow-up Index
1.58
1.52
Case Manager Availability Index
5.80
5.07
Broke Even or Made Profit
2.68
1.95
Quality Reporting Requirement Index
Public Recognition for Quality
Better Contracts for Quality
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3.16
2.13
12.34
9.03
7.3
5.48
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Implementation of the CCM
• Sub-sample analyses:
Physician-Owned
Hospital-Owned
(N = 527)
(N = 387)
17.19
7.55
Clinical IT Index
1.37
0.54
Group Visit Scheduling Index
1.79
2.36
Multiple Needs Scheduling Index
1.64
1.84
Follow-up Index
1.50
1.60
Case Manager Availability Index
5.21
4.74
Broke Even or Made Profit
1.21
1.31
Quality Reporting Requirement Index
2.24
2.00
Public Recognition for Quality
9.36
7.50
Better Contracts for Quality
7.27
2.73
Intercept
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Conclusions
• Ownership matters but
organizational resources and
external incentives are more
important for CCM implementation
– Receiving public recognition for quality
• The role of clinical IT among the
system-affiliated hospital-owned
POs warrants further investigation
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Policy Implications
Promoting greater implementation of
the Chronic Care Model requires:
– Organizational resources
• Clinical IT, scheduling capabilities, active
follow-up, and case manager availability
– Incentive mechanisms
• Requiring quality reporting, providing
public recognition for quality, and tying
quality improvement with better contracts
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Acknowledgements
• Dissertation study was funded by Health
Research and Education Trust (HRET)
Fellowship
• The NSPO project was funded by the
Robert Wood Johnson Foundation (RWJF)
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