Annual Review of Health Care Management: Revisiting The Evolution of Health Systems Organization: Volume 15

We discuss the impact of complexity science on the design and management of health care organizations over the past decade. We provide an overview of complexity science issues and their impact on thinking about health care systems, particularly with the rising importance of information systems. We also present a complexity science perspective on current issues in today’s health care organizations and suggest ways that this perspective might help in approaching these issues.

We review selected research, focusing on work in which we participated, to identify specific examples of applications of complexity science. We then take a look at information systems in health care organizations from a complexity viewpoint.

Complexity science is a fundamentally different way of understanding nature and has influenced the thinking of scholars and practitioners as they have attempted to understand health care organizations. Many scholars study health care organizations as complex adaptive systems and through this perspective develop new management strategies. Most important, perhaps, is the understanding that attention to relationships and interdependencies is critical for developing effective management strategies.

Increased understanding of complexity science can enhance the ability of researchers and practitioners to develop new ways of understanding and improving health care organizations.

This analysis opens new vistas for scholars and practitioners attempting to understand health care organizations as complex adaptive systems. The analysis holds value for those already familiar with this approach as well as those who may not be as familiar.

In this commentary, I highlight a few of the assertions made by McDaniel et al. (2013) about the importance of complexity science guided management practices, and extend these ideas specifically to how we might think about reducing seemingly intractable problems in health care such as patient safety, patient falls, hospital acquired infection, and the rise of chronic illness and obesity. I suggest that such changes will require managers and providers to view health care organizations and patients as complex adaptive systems and include patients as full participants in co-producing their health care.

Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway.

We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models.

The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners.

While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization.

Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices.

Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats.

This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.

To examine the evolution of health care integration strategies and associated conceptualization and practice through a review and synthesis of over 25 years of international academic research and literature.

A search of the health sciences literature was conducted using PubMed and EMBASE. A total of 114 articles were identified for inclusion and thematically analyzed using a strategy content model for systems-level integration.

Six major, inter-related shifts in integration strategies were identified: (1) from a focus on horizontal integration to an emphasis on vertical integration; (2) from acute care and institution-centered models of integration to a broader focus on community-based health and social services; (3) from economic arguments for integration to an emphasis on improving quality of care and creating value; (4) from evaluations of integration using an organizational perspective to an emerging interest in patient-centered measures; (5) from a focus on modifying organizational and environmental structures to an emphasis on changing ways of working and influencing underlying cultural attitudes and norms; and (6) from integration for all patients within defined regions to a strategic focus on integrating care for specific populations. We propose that underlying many of these shifts is a growing recognition of the value of understanding health care delivery and integration as processes situated in Complex-Adaptive Systems (CAS).

This review builds a descriptive framework against which to assess, compare, and track integration strategies over time.

The hospital–physician relationship (HPR) has been the focus of many scholars given the potential impact of this relationship on hospitals’ ability to achieve socially and organizationally desirable health care outcomes. Hospitals are dominated by professionals and share many commonalities with professional service firms (PSFs). In this chapter, we explore an alternative HPR based on the governance models prevalent in PSFs.

We summarize the issues presented by current HPRs and discuss the governance models dominant in PSFs.

We identify the non-equity partnership model as a governance archetype for hospitals; this model accounts for both the professional dominance in health care decisions and the increasing demand for higher accountability and efficiency.

There should be careful consideration of existing regulations such as the Stark law and the antikickback statue before the proposed governance model and the compensation structure for physician partners is adopted.

While our governance archetype is based on a review of the literature on HPRs and PSFs, further research is needed to test our model.

Given the dominance of not-for-profit (NFP) ownership in the hospital industry, we believe the non-equity partnership model can help align physician incentives with those of the hospital, and strengthen HPRs to meet the demands of the changing health care environment.

This is the first chapter to explore an alternative hospital–physician integration strategy by examining the governance models in PSFs, which similar to hospitals have a high reliance on a predominantly professional staff.

This chapter proposes a paradigm shift in considering the collective identification of employed physicians and how it influences physician engagement.

There are many challenges for organizations employing physicians, particularly in terms of engagement in organizational initiatives. Prior research suggests this conflict stems from how physicians think of themselves as professionals versus employees (as forms of collective identification). Unfortunately, research is limited in addressing these dynamics.

This conceptual chapter considers the complex network of relationships that physicians perceive between the collectives to which they belong. A primary collective identification (i.e., the profession) is proposed to influence subsequent collective identification (i.e., the organization), and that these meanings and relationships along with contextual factors drive engagement.

Health care organizations increasingly rely on engagement from their physicians to improve upon coordinated care. This proposed conceptualization offers new insight into the dynamics surrounding how and why employed physicians become engaged.