Organization and Performance of US Health Systems

JAMA. 2023 Jan 24;329(4):325-335. doi: 10.1001/jama.2022.24032.


Importance: Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.

Objective: To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.

Evidence review: Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.

Findings: A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.

Conclusions and relevance: In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.

Publication types

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

MeSH terms

  • Aged
  • Delivery of Health Care* / economics
  • Delivery of Health Care* / organization & administration
  • Delivery of Health Care* / standards
  • Delivery of Health Care* / statistics & numerical data
  • Government Programs
  • Hospital Administration* / economics
  • Hospital Administration* / standards
  • Hospitals / classification
  • Hospitals / standards
  • Hospitals / statistics & numerical data
  • Humans
  • Medicare / economics
  • Medicare / statistics & numerical data
  • Patient Readmission / statistics & numerical data
  • Quality of Health Care* / economics
  • Quality of Health Care* / organization & administration
  • Quality of Health Care* / standards
  • Quality of Health Care* / statistics & numerical data
  • United States / epidemiology