Literature Collection

OBJECTIVES: Hospital employment of physicians, often called hospital-physician vertical integration, has become widespread in health care delivery, but whether hospital employment tilts the case mix of physicians toward higher-complexity patients remains unknown. STUDY DESIGN: Cross-sectional and difference-in-differences analysis of 2014-2019 Medicare Standard Analytic Files. METHODS: We compared pre- and postemployment patient panels of primary care physicians who did and did not become hospital employees, analyzing changes in the prevalence of chronic conditions. We measured arthritis, depression, diabetes, hypertension, and ischemic heart disease. We also evaluated whether patients who were dropped from physician panels found alternative sources of primary care. RESULTS: Hospital-employed physicians treated patients of similar or better health; for instance, 54% of integrated physicians' patients had 2 or more chronic conditions compared with 56% among independent physicians (P < .001). After becoming hospital employees, physicians treated approximately 10% fewer Medicare patients (-9.5%; 95% CI, -11.3% to -7.7%). Within physician panels, the prevalence of patients with 2 or more chronic conditions did not significantly change after employment relative to independent physicians (-1.1%; 95% CI, -2.3% to 0.2%). Approximately 37% of patients were dropped from physician panels after employment; these patients were less likely to find alternative primary care compared with those dropped from independent physician panels (P < .001). CONCLUSIONS: Hospital employment of physicians resulted in neither a higher number nor a higher proportion of complex patients treated by integrated physicians, at least among traditional Medicare patients.

OBJECTIVES: The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS: We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ(2) test to evaluate the effect of the educational intervention on screening. RESULTS: Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS: Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.

BACKGROUND: New models of care that integrate health and social care provision around the patient require a supportive infrastructure, including interorganizational arrangements and information systems. While public policies have been designed to facilitate visions of integrated care, these often neglect the implementation of effective and efficient delivery mechanisms. METHOD: This study examines a decade of attempts to move from fragmented health and care delivery to integrated care at scale in NHS England by developing and implementing a support infrastructure. We undertook a longitudinal qualitative investigation -encompassing interviews and documentary analysis- of the implementation of interorganizational and digital interoperability infrastructures intended to support integrated care policies. FINDINGS: Our findings underscore the long-term symbiotic relationship between institutional interorganizational frameworks and the construction of interoperability infrastructures, emphasizing how they mutually reinforce each other to support their ongoing evolution. Iterative, flexible, and experimental approaches to implementation provide opportunities to adapt to local realities while learning in the making. CONCLUSION: This study underlines the importance of adaptable, locally-informed implementation strategies in supporting the vision of integrated care, and the need to understand such development as a long-term, ongoing process of construction and learning.