Alternative models of hospital-physician affiliation as the United States moves away from tight managed care.

Using concepts from organizational economics and sociology, this article compares the medical staff, hospital-owned physician practice, and hybrid models of hospital-physician coordination, as well as the pressures for affiliation during the premanaged care, tight managed care, and loose managed care eras. Case studies of two hospital systems in New York City and two in San Diego illustrate the concepts. Although pressures for tighter hospital-physician affiliation now are weaker than during the era of tight managed care, they are greater than they were before managed care. Hospitals are not reverting to exclusive use of the medical staff model of affiliation but rather are maintaining a mix of medical staff, owned physician practice, and hybrid models. Hospitals probably will continue to seek tighter affiliations with physicians to increase coordination, enhance negotiating leverage with health plans, and gain admissions.