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Clustered and distinct: a taxonomy of local multihospital systems

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Abstract

Despite their prevalence and power in markets throughout the United States, local multihospital systems (LMSs)—also referred to as hospital-based “clusters”—remain an understudied organizational form, with studies instead primarily focusing either upon individual hospitals or viewing hospital systems collectively without distinguishing the local “sub-systems” that comprise larger regional or national hospital chains. To better understand these organizational forms, we develop a taxonomy specifically devoted to LMSs, applying taxonomic analysis methods to a sample of LMSs in six U.S. states while accounting for LMSs’ geographic arrangements and non-hospital-based service locations. Our analysis identifies five distinct LMS categories, with forms clearly distinguished according to their varying degrees of differentiation and integration. The study’s results accentuate the importance of accounting for hospital systems’ activities and arrangements in local markets—including their non-hospital-based sites—and highlight differences in systems’ achievement of integration and coordination across services and locations, providing considerations in light of U.S. health system reform as well as international patterns of regional system formation.

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Notes

  1. We recognize the potential for confusion between Porter’s use of the term “configuration” and others’ approaches to the term “configuration,” including the shape of organizational role structures [19] as well as in relation to configuration or archetype theory [e.g., 20, 21]. For this reason, we use the term “spatial differentiation” to refer to the concepts described in Porter’s definition of configuration.

  2. Figure 1 is adapted from similar depictions of the continuum of care by Conrad and colleagues [23: 54, 29: 493], Mick and Conrad [26: 351], and Clement [28: 103]. These depictions recognize different stages along the continuum of care, represented in Fig. 1 as “Inputs to Services,” “Direct Service Outputs,” “Episodic Service Outputs,” and “Chronic Service Outputs.” Within each of these stages, different categories of service or product settings are identified, as shown in Fig. 1. Examples of “Education of Labor” sites operated by LMSs include nursing schools, therapy schools, and management schools, and “Medical Equipment” sites include durable medical equipment vendor locations. “Ancillary Services” settings include diagnostic laboratories, diagnostic imaging centers, and pharmacies, while “Wellness & Health Promotion” sites include fitness and wellness centers, diabetes clinics, and pregnancy testing and education facilities. “Primary Care” locations refer to primary care physician practices and clinics, and “Specialty Physician Care” locations refer to specialty physician practices and clinics. Examples of “Acute Outpatient Care” settings include ambulatory surgery centers, sleep clinics, and wound care clinics. “Non-Physician Provider Care” locations refer to sites providing care primarily through the services of non-physician providers, such as retail clinics, outpatient rehabilitation clinics, behavioral health clinics, and occupational health clinics. “Urgent & Emergency Care” sites include freestanding emergency centers and urgent care clinics. “General Hospital Inpatient Care” refers to services provided within general, acute care hospitals, and “Specialty Hospital Inpatient Care” refers to services provided within specialty hospitals such as heart hospitals and surgical hospitals. Examples of “Short-term Inpatient Rehab & Nursing” settings include inpatient rehabilitation facilities and behavioral health hospitals, while “Long-term Inpatient Rehab & Nursing” sites include long-term acute care hospitals and skilled nursing facilities. “Outpatient Rehab & Nursing” refers to LMS services such as home health and comprehensive outpatient rehabilitation facilities, and “Extended Care & Living” locations are settings such as long-term care facilities, assisted living facilities, continuing care retirement communities, adult day care centers, and hospice homes. “Multi-Service Outpatient Centers” may include varied combinations of ancillary, wellness & health promotion, primary care, acute & specialty outpatient care, non-physician provider care, or urgent and emergency care services.

  3. Additional information regarding the study’s data sources, including substitution of AHA 2010 Annual Survey data and instances in which LMSs lacked observations for individual facilities, is available upon request.

  4. A detailed listing of each service variable and its assigned stage, as well as a listing of corresponding service location types identified in primary data collection, is available upon request.

  5. A comparison of agreement rates between the final solution and alternative cluster analysis results is available upon request.

  6. Separate discriminant analyses were also performed for cross-validation purposes, using a within-groups covariance matrix, equal prior probabilities, and split-sample validation methods. Each of the classification rates obtained from these multiple discriminant analyses greatly exceeded the recommended classification accuracy, indicating that the final cluster groupings are internally valid and reliable. A comparison of these results is available upon request.

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Acknowledgments

The authors wish to thank Dr. Carl F. Ameringer, Dr. Roice D. Luke, Dr. Carolyn A. Watts, and anonymous reviewers for their valuable comments on previous versions of this article.

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Correspondence to Patrick D. Shay.

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Shay, P.D., Mick, S.S.F. Clustered and distinct: a taxonomy of local multihospital systems. Health Care Manag Sci 20, 303–315 (2017). https://doi.org/10.1007/s10729-016-9353-7

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