Association of Multiple Hospital Affiliations With Clinician Service Use, Breadth of Procedures, and Costs
Authors: Sebastian Linde, Svetlana Beilfuss
Journal: JAMA Network Open (2021)

<h3>Importance</h3> Little is known about whether a clinician having multiple hospital affiliations (ie, 1 clinician working across multiple teams and organizations) is associated with clinician practice style and cost. The measurement of this association requires adjusting for selection into multihospital affiliations based on both observable and unobservable clinician characteristics. <h3>Objective</h3> To evaluate the association of multiple hospital affiliations with clinician service use, breadth of procedures used, and costs. <h3>Design, Setting, and Participants</h3> This cohort study used Medicare Part B data from 2016 through 2017 in a fixed-effects panel data design to compare service use, procedure breadth, and costs between clinicians with multiple affiliations (treatment group) and clinicians with a single affiliation (control group), with adjustment for volume, patients, and clinician characteristics. The study also controlled for unobserved (time-invariant) clinician characteristics using individual clinician fixed effects. Clinicians with Medicare claims, a reported National Provider Identifier, and affiliation data within Medicare Physician Compare were included for a total sample of 1 073 252 observations (633 552 unique clinicians) for medical services and 358 669 observations (210 260 unique clinicians) for drug prescribing. Statistical analyses were performed from February 1 to October 15, 2021. <h3>Main Outcomes and Measures</h3> Service use is the total number of medical (or drug) services that clinicians render to their Medicare beneficiaries within a given year, procedure breadth is the total number of unique Healthcare Common Procedure Coding System codes that are associated with clinicians’ medical (or drug) services within a given year, and costs represent the total standardized amount paid by Medicare for the medical (or drug) services. Additional measures were multiple-hospital affiliations, Accountable Care Organization affiliation, and controls across clinician and patient characteristics. <h3>Results</h3> The medical service sample consisted of 633 552 clinicians (248 359 women [39.2%]; mean [SD] of 19.6 [12.5] years of experience), and the drug service sample consisted of 210 260 clinicians (74 875 women [35.6%]; mean [SD] of 21.6 [12.3] years of experience). For medical services, clinicians with multiple practice affiliations used a mean 8.2% (95% CI, 7.5%-8.9%;<i>P</i> &lt; .001) more medical services per patient, drew on a mean 5.4% (95% CI, 5.1%-5.7%;<i>P</i> &lt; .001) wider set of procedures within their medical care, and incurred a mean 8.6% (95% CI, 7.9%-9.2%;<i>P</i> &lt; .001) more in medical costs. Pertaining to drug services, clinicians with multiple practice affiliations used a mean 2.9% (95% CI, 1.9%-3.9%;<i>P</i> &lt; .001) more drug services per patient, drew on a mean 1.0% (95% CI, 0.5%-1.4%;<i>P</i> &lt; .001) wider set of procedures within their medical care, and incurred a mean 2.7% (95% CI, 1.6%-3.7%;<i>P</i> &lt; .001) more in drug costs. Significant results were also found across extensive and intensive margins of hospital affiliation, and supplemental analysis further indicated heterogenous treatment associations across clinician specialties. <h3>Conclusions and Relevance</h3> This cohort study found that a clinician having multihospital affiliations was associated with greater service use, procedure breadth, and costs across both medical and drug services. These findings suggest that clinician affiliations ought to be considered as part of health care delivery design and potential cost-containment strategies.