Physician Affiliations: The Good, The Bad, The Future:

Recent changes in demographics, technology and the delivery and compensation (e.g., Accountable Care Organizations (ACOs) and “bundled payments”) of health care has pushed hospitals into mergers and affiliations with other hospitals and independent practitioners.

Hospitals know that affiliations and mergers help with: Managing lower reimbursement rates from public and private insurers

  • Managing lower reimbursement rates from public and private insurers
  • Allow easier access to capital
  • Increase efficiency

Affiliations also help lower business overhead (billing, insurance negotiations, owning electronic medical record system) thus granting more time to see patients [1].

Private-practice doctors have a tremendous value to hospitals: patients to fill beds, outpatient labs in the hospital and private insurance (which typically pay more than Medicare and Medicaid programs).

It needs to be noted there are negative effects of local physician/hospital consolidation (mostly for the patient) including [2]:

  • Growth in prices for patients, at least for some proceduresReduction in hospital quality for patients
  • Reduction in hospital quality for patients
  • Minimize physician independence

During the 1990s, hospitals began to hire doctors from private practices. The first wave of this trend failed due to a scarce system of incentives once the doctor became a hospital employee. This led to a decline in productivity, ultimately reinstating the independent practitioner.

Hospitals now claim to be better equipped to manage doctors.

Patterns of Affiliation

In order to give some answers to the many questions that arise from the practice of affiliations, we examine patterns of affiliations for primary care doctors1. Using data for Q4, 2014 and Q1, 2016, we examined the differences (if any) in the number, state and typology of the institution for affiliations in the last year.

Male vs. Female Affiliations

Figure 1 demonstrates the tendency for females to report only a single affiliation compared to up to five affiliations males report.

Figure 1: Affiliation frequencies by gender.

Figure 2 shows the Q4, 2014 and Q1, 2016 change in the number of affiliations per doctor, divided by gender. For the majority of doctors, there were no changes in the number of affiliations suggesting a status quo equally distributed among male and female physicians. Even considering the year of graduation, the result shows the same trend for the majority of doctors—no change in the number of affiliations.

Figure 2: Changes in a number of affiliations.

Affiliations nationwide

Let’s have a look at how affiliations are distributed nationwide. According to the latest Q1, 2016, doctors have 2.35 affiliations nationwide. Figure 3 compares the fluctuation in the average number of affiliations per doctor in each state to Q4, 2014: the status quo is confirmed. The slight increase seems to be localized mainly in New England and Plains regions while the slight decrease is mainly concentrated in the Far West and the Rocky Mountains regions.

Figure 3:

Of course, a doctor can have affiliations (and a license) in more than one state. Figure 4 illustrates the diffusion of affiliations in more than one state. The average number of affiliations per doctors in states different from that of their employer is 0.24 points. Figure 5 illustrates the difference in such value from Q4, 2014 and Q1, 2016. There is a general tendency to the status quo, but four states do register an outlier behavior: Alaska (decreased -0.18 points) and North Dakota (decreased -0.12 points) versus Kansas and Wyoming (increased 0.10 points).

Figure 4:

Even if the average number of affiliations in different states is stable for the majority of primary care physicians – i.e. we register no change in the period Q4 2014 – Q1 2016, what is the flow of physicians between states? Figure 5 illustrates such a flow in the past year. One interesting finding is that doctors who remain in the same state have a lower average number of affiliations compared to physicians who changed states (2.14 points versus 2.64 points).

Figure 5 shows regions as nodes, where the size of each node is proportional to the number of physicians received from other regions. The width of a link is proportional to the amount of physician that moved to a different region. There is a consistent flow of doctors between Mideast and Southeast. There is also a strong flow from Great Lakes to Southeast and from Great Lakes to Southwest (not entirely reciprocated). Finally, we can observe a consistent flow from Southeast to Southwest.

FIGURE 5: Physicians flow between regions.

The average number of affiliations (as well as the composition by state) has not changed significantly since last year; however, we do observe migrations from different regions. What can we say about changes in the type of institution affiliated? Figure 6 shows changes in affiliation regarding the institution type. We recoded changes in these affiliations between the two periods considered presented in a flow graph (Figure 6).Affiliations between institution types

Affiliations between institution types

The most distinctive dynamic flow for primary care doctors is the switch between “No Affiliation” and “Short-term Hospitals”. This back and forth process suggests the periodical refill of structural vacancies.
The second order of dynamic processes involves doctors switching back and forth between “No Affiliation” and “Critical-Access Hospitals” and doctors switching between “Critical-Access Hospitals” and “Short-term Hospitals”. In particular, the latter flow is indicative of a connection between Critical-Access and Acute-Care hospitals.

Figure 6: Types of Institutions.

Change in Affiliation List

Now we have to explore the last, but potentially, most interesting pattern: the type of changes in the affiliations list. Since we can have up to five affiliations listed for each physician, there are many possible changes that can occur. We have observed around 30 different patterns in the data, but the most distinctive and frequent are the six depicted in Figure 7.

Figure 7: Most common pattern changes in Affiliations.

Conclusion

There is an ongoing process in the healthcare space that is pushing doctors to link to hospitals: employment is the strictest form while affiliation is still under scrutiny to understand its long-term effects on the system. Many primary care physicians maintain a single affiliation or two. Others experiment with a variety of combinations where only the first affiliation remain stable—this is a confirmation of the turbulence in the healthcare space.
We are still on the acceleration curve, so we should expect and adapt to quick changes; however, affiliations seem to be an interesting indicator of physician choices and a useful predictor of future trends.

————————————————————————————————————————-

This article was written by Simone Gabbriellini, Co-founder and Chief Analytics Officer of DocDelta.

DocDelta is a healthcare technology company based in New York. DocDelta has developed new technology that makes it really easy for healthcare managers to hire and retain the best nurses and doctors, currently increasing hiring/retention efficiency by 50%.

Our sourcing and flight risk analytics tools give healthcare administrators the edge in hiring and retaining the very best nurses and physicians.

Find us on FaceBook | LinkedIn | Twitter

References
1. Gaynor M, Town R. The Impact of Hospital Consolidation—Update. THE ROBERT WOOD JOHNSON FOUNDATION; 2012.
2. Madison K. Hospital–Physician Affiliations and Patient Treatments, Expenditures, and Outcomes. Health Services Research. 2004;39(2).