BACKGROUND: Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems. OBJECTIVES: Compare the characteristics, quality, and costs of care between small and large health systems. RESEARCH DESIGN: Retrospective, repeated cross-sectional analysis. SUBJECTS: Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017. MEASURES: We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs. RESULTS: The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care. CONCLUSIONS: Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.
BACKGROUND: Research on US health systems has focused on large systems with at least 50 physicians. Little is known about small systems. OBJECTIVES: Compare the characteristics, quality, and costs of care between small and large health systems. RESEARCH DESIGN: Retrospective, repeated cross-sectional analysis. SUBJECTS: Between 468 and 479 large health systems, and between 608 and 641 small systems serving fee-for-service Medicare beneficiaries, yearly between 2013 and 2017. MEASURES: We compared organizational, provider and beneficiary characteristics of large and small systems, and their geographic distribution, using multiple Medicare and Internal Revenue Service administrative data sources. We used mixed-effects regression models to estimate differences between small and large systems in claims-based Healthcare Effectiveness Data and Information Set (HEDIS) quality measures and HealthPartners' Total Cost of Care measure using a 100% sample of Medicare fee-for-service claims. We fit linear spline models to examine the relationship between the number of a system's affiliated physicians and its quality and costs. RESULTS: The number of both small and large systems increased from 2013 to 2017. Small systems had a larger share of practice sites (43.1% vs. 11.7% for large systems in 2017) and beneficiaries (51.4% vs. 15.5% for large systems in 2017) in rural areas or small towns. Quality performance was lower among small systems than large systems (-0.52 SDs of a composite quality measure) and increased with system size up to ∼75 physicians. There was no difference in total costs of care. CONCLUSIONS: Small systems are a growing source of care for rural Medicare populations, but their quality performance lags behind large systems. Future studies should examine the mechanisms responsible for quality differences.
Authors: Lawrence P Casalino; Frances M Wu; Andrew M Ryan; Kennon Copeland; Diane R Rittenhouse; Patricia P Ramsay; Stephen M Shortell Journal: Health Aff (Millwood) Date: 2013-08 Impact factor: 6.301
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Authors: Michael F Furukawa; Laura Kimmey; David J Jones; Rachel M Machta; Jing Guo; Eugene C Rich Journal: Health Aff (Millwood) Date: 2020-08 Impact factor: 6.301
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