The impact of physician-hospital integration on spending and quality of oncology care.
Authors: Kakani Pragya , Beaulieu Nancy , Brooks Gabriel A. , Gray Stacy W. , Wright Alexi A. , Chernew Michael , Cutler David M , Landrum Mary Beth , Keating Nancy Lynn 
Published: June 2022

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Background: There has been increasing hospital and health system ownership of physician practices in recent years, particularly in oncology. However, relatively little is known about how this impacts care delivery for patients with cancer, who use many hospital-based services that may be impacted by integration. We evaluated the impact of physician-hospital integration in oncology on spending and quality of care for Medicare beneficiaries with cancer. Methods: We used Medicare Fee-for-Service claims from 2005-2019 linked with a unique Health System and Provider Database, developed by National Bureau of Economic Research and Harvard University researchers, to track practice ownership relationships over time. We used a stacked event study to assess outcomes for patients three years before and after oncologists move from independent practices to hospital- or system- owned practices. We compared outcomes to a control group with oncologists who shifted from independent to hospital- or system-owned practices in later years. We focused on two cohorts of patients. The first cohort included cancer patients with presumed incident or recurrent cancer based on ≥2 visits to an oncologist and no visit in the past year. For these patients, we evaluated the impact of physician-hospital integration on the likelihood of receiving chemotherapy following the visit. The second cohort included 6-month episodes for patients receiving chemotherapy. For these patients we evaluated the impact of physician-hospital integration on spending, utilization, and quality. Quality measures included receipt of timely chemotherapy (within 60 days) following surgery, inpatient readmissions, non-use of tamoxifen + strong CYPD26 inhibitors, and end-of-life intensity of care measures. Results: There was no change in the likelihood of receiving chemotherapy with an initial oncology consultation following an oncologist’s transition to hospital-based employment. Total spending during six-month chemotherapy episodes increased by $1391 (95%CI: $465, $2316). The primary contributors to this growth were increases in spending on inpatient care, chemotherapy administration, and office visits. Spending growth, where observed, was driven primarily by higher Medicare prices for care in hospital outpatient settings. We found no positive impact of physician-hospital integration on timeliness of chemotherapy initiation, readmissions, concurrent use of tamoxifen+strong CYPD26 inhibitors, or intensity of end-of-life care. Conclusions: Physician-hospital integration resulted in higher prices and thus higher spending, but had limited impact on utilization and no detectable impacts on measures of quality. These results suggest that claims of quality improvements and concerns regarding overuse associated with physician-hospital integration may be overstated. Our results also support continued movement towards site-neutral payments.