Provider accountability as a driving force towards physician–hospital integration: a systematic review

BACKGROUND: Hospitals and physicians lie at the heart of our health care delivery system. In general, physicians provide medical care and hospitals the resources to deliver health care. In the past two decades many countries have adopted reforms in which provider financial risk bearing is increased. By making providers financially accountable for the delivered care integrated care delivery is stimulated. PURPOSE: To assess the evidence base supporting the relationship between provider financial risk bearing and physician–hospital integration and to identify the different types of methods used to measure physician–hospital integration to evaluate the functional value of these integrative models. RESULTS: Nine studies met the inclusion criteria. The evidence base is mixed and inconclusive. Our methodological analysis of previous research shows that previous studies have largely focused on the formal structures of physician–hospital arrangements as an indicator of physician–hospital integration. CONCLUSION: The link between provider financial risk bearing and physician–hospital integration can at this time be supported merely on the basis of theoretical insights of agency theory rather than empirical research. Physician–hospital integration measurement has concentrated on the prevalence of contracting vehicles that enables joint bargaining in a managed care environment but without realizing integration and cooperation between hospital and physicians. Therefore, we argue that these studies fail to shed light on the impact of risk shifting on the hospital–physician relationship accurately.