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Physician consolidation into health systems increased in nearly all metropolitan statistical areas (MSAs) from 2016 to 2018. Of the 382 US MSAs, 113 had more than half of their physicians in health systems in 2018. Consolidation of physicians was most notable in the Midwest and Northeast and in small-to-midsize MSAs.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.

Importance: Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation., Objective: To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices., Design, Setting, and Participants: A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019., Exposures: Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors., Main Outcomes and Measures: Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts., Results: A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation., Conclusions and Relevance: Greater APM participation appears to be supported by integration and system ownership.

We conduct a narrative literature review using four real-world cases of clinical decisions to show how barriers to the use of evidence-based medicine affect physician decision-making at the point of care, and where adjustments could be made in the healthcare system to address these barriers. Our four cases constitute decisions typical of the types physicians make on a regular basis: diagnostic testing, initial treatment and treatment monitoring. To shed light on opportunities to improve patient care while reducing costs, we focus on barriers that could be addressed through changes to policy and/or practice at a particular level of the healthcare system. We conclude by relating our findings to the passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act in April 2015.

Background: Governments around the world exert a substantial degree of influence over physician reimbursement, but the structure and level of that influence varies greatly. This article defines and analyzes the role of government in physician reimbursement both internationally and in the United States., Analytical Framework: We create a typology for government involvement in physician reimbursement that divides intervention into either direct control or indirect control. Within those broad categories, we describe more specific forms of involvement including rate setting, operating as a public payer, employing physicians directly, providing a source of market discipline, regulating private insurance, and convening private participants in the market., Findings: We apply our framework to the modern healthcare systems of Germany, Sweden, Canada, and the United States, highlighting some of the implications of differences between the systems. Our central finding is that in contrast to other example healthcare systems, the United States system features a complex interplay of federal and state government influence, both direct and indirect, into physician reimbursement., Conclusion: We conclude the article by examining the ways in which recent legislation including the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act would likely change the role of government in physician reimbursement in the United States., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Databases of practicing physicians are important for studies that require sampling physicians or counting the physician population in a given area. However, little is known about how the three main sampling frames differ from each other., Objective: Our purpose was to compare the National Provider and Plan Enumeration System (NPPES), the American Medical Association Masterfile and the SK&A physician file., Methods: We randomly sampled 3000 physicians from the NPPES (500 in six specialties). We conducted two- and three-way comparisons across three databases to determine the extent to which they matched on address and specialty. In addition, we randomly selected 1200 physicians (200 per specialty) for telephone verification., Key Results: One thousand, six hundred and fifty-five physicians (55 %) were found in all three data files. The SK&A data file had the highest rate of missing physicians when compared to the NPPES, and varied by specialty (50 % in radiology vs. 28 % in cardiology). NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES. We were able to confirm 65 % of physicians' address information by phone. The NPPES and SK&A had similar rates of correct address information in phone verification (72-94 % and 79-92 %, respectively, across specialties), while the AMA Masterfile had significantly lower rates of correct address information across all specialties (32-54 % across specialties)., Conclusions: None of the data files in this study were perfect; the fact that we were unable to reach one-third of our telephone verification sample is troubling. However, the study offers some encouragement for researchers conducting physician surveys. The NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and provider insurers.

Objective: To examine patient perceptions of professional appropriateness and the potential impact on health care of physician acceptance of gifts from the pharmaceutical industry., Design: A random-digit dialing telephone survey., Setting and Participants: A sample of 649 adults (> or = 18 years old) living in Kentucky., Main Outcome Measures: Patient awareness of office-use gifts (eg, pens, notepads) and personal gifts to physicians from the pharmaceutical industry, patient exposure to office-use gifts, and attitudes toward physician acceptance of both office-use and personal gifts., Results: The survey had a response rate of 55%. Eighty-two percent of the respondents were aware that physicians received office-use gifts, while 32% were aware that physicians received personal gifts. Seventy-five percent reported receiving free samples of medication from their physicians. Compared with office-use gifts, more respondents believed that personal gifts to physicians have a negative effect on both health care cost (42% vs 26%) and quality (23% vs 13%). After controlling for demographic variables, as well as awareness and exposure to physician gifts, individuals with at least a high school education were 2.4 times as likely to believe that personal gifts have a negative effect on the cost of health care and 2.3 times as likely to believe that personal gifts would have a negative effect on the quality of health care., Conclusions: These results suggest that the public is generally uninformed about personal gifts from pharmaceutical companies to physicians. If public perception regarding the objectivity of the medical profession is to serve as a guide, these findings suggest a reevaluation may be in order for guidelines regarding physician acceptance of gifts from the pharmaceutical industry.

The recurring decision of selecting among potential knowledge resources was modeled as a cost-benefit tradeoff, with associated observable features. Internal medicine and community family practice physicians (n = 228) completed a self-administered questionnaire designed to elicit reported use and cost-benefit features of nine knowledge resources. The subjects reported most frequent use of clinical colleagues, intermediate use of textbooks and journals, and least use of indexing systems. Resources' benefit-related qualities (extensiveness and credibility) were not related to reported use. In contrast, the model's access cost variables (availability, searchability, understandability, and clinical applicability) were significantly related to use. Results were generally favorable to the model's framework of knowledge resource selection. Multiple linear regression analysis suggested that physicians' use of clinical knowledge resources could be described by the physician's level of training, availability, applicability, and the resource medium (colleague, index, or text/journal).