Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries

Health Serv Res. 2020 Dec;55 Suppl 3(Suppl 3):1085-1097. doi: 10.1111/1475-6773.13580. Epub 2020 Oct 26.


Objective: To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes.

Data sources: Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data.

Study design: Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse.

Data collection/extraction methods: 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions).

Principal findings: Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]).

Conclusions: Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Keywords: Medicare; health care organizations and systems; integration.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Clinical Protocols / standards
  • Continuity of Patient Care / organization & administration*
  • Continuity of Patient Care / standards
  • Cross-Sectional Studies
  • Efficiency, Organizational
  • Fee-for-Service Plans / statistics & numerical data
  • Group Practice / organization & administration*
  • Group Practice / standards
  • Health Information Systems
  • Health Services Research
  • Humans
  • Medicare / statistics & numerical data*
  • Outcome and Process Assessment, Health Care
  • Physicians / organization & administration*
  • Physicians / standards
  • Quality of Health Care
  • United States