Health Systems, Quality and Variation

Integrated health systems are becoming more important due to increasing trends toward consolidation in the midst of rapidly expanding health care reform efforts enacted by the Affordable Care Act. Consolidated health systems have advantages which include the ability to coordinate care across providers and care settings. Conceptually, health systems might be better equipped to achieve the breadth of alignment (i.e., social, functional and clinical) required to redesign and sustain care processes to achieve quality improvement due to greater capacity for monitoring and managing performance. However, enormous variation exists across health systems in terms of their organizational characteristics and operations. Yet, little knowledge exists regarding how or why quality of care varies at this level due to a lack of systematically collected data regarding health system affiliations, system characteristics or their behaviors to achieve true clinical integration to further quality goals. In Chapter 1, we assess variation in quality performance across and within health systems to understand the extent to which health systems differ in their overall quality and the care they provide to vulnerable populations. I find that there is small variability in overall care quality across health systems; system-level intraclass correlation coefficients (ICCs) for quality outcomes are generally low, ranging from 0.05% to 1.79%. Although ICCs were small, system-level means ranged from 75%-80%, 73%-81%, and 67%-77% for the A1c, LDL and breast cancer screening measures, respectively. We find that there are systematic differences in observable quality performance for certain vulnerable patient groups compared to non-vulnerable patient groups and there is large variation in the extent of health disparities across health systems. Health systems are uniquely positioned to improve care delivery and care quality, making a strong case deployment of an incentive-driven system directed at health systems aimed at standardizing high quality care delivery for patients in certain demographic groups. Study findings support the notion that monitoring quality of care at the health system-level is valuable for advancing health care reform. In Chapter 2, we examine the empirical relationships between individual structural features of the organization and quality. We document statistically significant relationships among the constructed structural characteristics studied and quality performance. For