Article review 6

Introduction
The U.S. health care delivery system is characterized by
complexity. Individuals obtain health insurance through
private or public sources that target certain patient
populations on the basis of employment, age, disability
status, income status, military service, or other factors,
while a portion of society remains uninsured for vari-
ous reasons. The result of this heterogeneous coverage
environment is that multiple players, including federal
and state policymakers and private payers, influence the
health care delivery system and patient care. These play-
ers develop eligibility policies, determine which services
will be covered, contract with provider networks, establish
provider reimbursement models, and engage in some
level of care management. At the same time, hospitals,
physicians, and other providers, such as post-acute care

providers, are structurally and contractually organized in
diverse arrangements, with varying levels of autonomy.

Compared to many other industrialized countries, the
U.S. health care system has been found to incur higher
costs but yield lower access, quality, and population health
outcomes [1]. Like other countries, U.S. policymakers and
payers have viewed integrated care as a strategy for improv-
ing health care quality and efficiency. “Integrated care” has
been defined as “a coherent set of methods and models
on the funding, administrative, organizational, service
delivery and clinical levels designed to create connectivity,
alignment and collaboration within and between the cure
and care sectors” [2].

Various U.S. federal and state policies, as well as local
market factors, have influenced how, and which types
of, providers work together to care for patient popula-
tions. Although the integration of providers has been a
persistent strategy, the type of integration and its goals
have varied over time. Between the 1980s and mid-1990s,
the U.S. health care delivery system experienced a shift
in the predominant type of integration—from horizon-
tal integration, when organizations acquire or integrate

RESEARCH AND THEORY

Horizontal and Vertical Integration of Health Care
Providers: A Framework for Understanding Various
Provider Organizational Structures
Jessica Heeringa*, Anne Mutti*, Michael F. Furukawa†, Amanda Lechner*, Kristin A. Maurer*
and Eugene Rich*

Introduction: Current U.S. policy and payment initiatives aim to encourage health care provider account-
ability for population health and higher value care, resulting in efforts to integrate providers along the
continuum. Providers work together through diverse organizational structures, yet evidence is limited
regarding how to best organize the delivery system to achieve higher value care.
Methods: In 2016, we conducted a narrative review of 10 years of literature to identify definitional
components of key organizational structures in the United States. A clear accounting of common organi-
zational structures is foundational for understanding the system attributes that are associated with
higher value care.
Results: We distinguish between structures characterized by the horizontal integration of providers
delivering similar services and the vertical integration of providers fulfilling different functions along
the care continuum. We characterize these structures in terms of their origins, included providers and
services, care management functions, and governance.
Conclusions and discussion: Increasingly, U.S. policymakers seek to promote provider integration and
coordination. Emerging evidence suggests that organizational structures, composition, and other charac-
teristics influence cost and quality performance. Given current efforts to reform the U.S. delivery system,
future research should seek to systematically examine the role of organizational structure in cost and
quality outcomes.

Keywords: vertical integration; horizontal integration; health systems; integrated care

* Mathematica Policy Research, US
† Agency for Healthcare Research and Quality, US
Corresponding author: Jessica Heeringa
([email protected])

Heeringa, J, et al. Horizontal and Vertical Integration of Health Care Providers: A
Framework for Understanding Various Provider Organizational Structures. International
Journal of Integrated Care, 2020; 20(1): 2, 1–10. DOI: https://doi.org/10.5334/ijic.4635

mailto:[email protected]

https://doi.org/10.5334/ijic.4635

Heeringa et al: Horizontal and Vertical Integration of Health Care ProvidersArt. 2, page 2 of 10

with other organizations that provide the same or similar
services such as multihospital systems or multispecialty
practice organizations [3]—to vertical integration, when
organizations acquire or integrate with organizations
offering different levels of care, services, or functions such
as hospital ownership of physician practices [3, 4].

Major policy shifts, such as the Patient Protection and
Affordable Care Act (ACA) of 2010, have in part fueled
a resurgence in efforts to promote integrated care.
Increasingly, hospitals, physicians, and other providers are
consolidated into health systems [5, 6]. This trend toward
the vertical integration of various provider types has
occurred while there has been a shift in U.S. policymaker
attention to improving health outcomes and patient-
centeredness as elements of health care value [4]. The
ACA established multiple programs and policies to test
new delivery system and payment models that emphasize
improved access to care and care management along the
care continuum, furthering the incentives for integra-
tion among providers [7]. For example, growing financ-
ing and delivery system models, such as accountable care
organizations (ACOs) and patient-centered medical homes
(PCMHs), are built on a foundation of primary care, shared
accountability, and improved care management [4, 7].

Following the ACA, private and public sector payers
have been shifting from fee-for-service reimbursement
models to risk-based models that encourage shared
accountability for the total costs of care between payers
and providers. Collectively, these emerging payment and
delivery system models encourage coordination and inte-
gration across providers to ultimately improve quality and
cost outcomes [8].

Despite the adoption of integration as a primary reform
strategy, there is presently a gap in evidence regarding
which underlying structural changes in local health care
delivery systems are most effective in achieving higher
value care [9]. To address this gap in evidence, the U.S.
Agency for Healthcare Research and Quality (AHRQ)
established the Comparative Health System Performance
Initiative [10]. As a formative step in this initiative, we
conducted a review of the literature spanning 10 years to
identify the core elements of organizational structures in
the U.S. health care system and describe them with respect
to their included health care providers and services, care
management functions, and administrative oversight of
included providers. A clear accounting of these common
organizational structures is foundational to ongoing work
to understand the core characteristics of systems that are
associated with improved quality and cost outcomes.

Methods
In September 2016, we conducted a narrative review of
10 years of literature to identify definitional components,
care management functions, and administrative over-
sight of key organizational structures. To characterize
care management, we looked for information regarding
each organizational structure’s role in coordinating and
managing the care of defined patient populations and
available resources and capacity within each structure to
facilitate care management, such as health information

technology. To understand how the administrative over-
sight of included providers varied across organizational
structures, we examined descriptions of constructs such
as the governance of included providers, the nature of
relationships among providers (for example, contractual
relationships), and the extent to which included providers
retain professional autonomy in each structure.

For this narrative overview, we began with a foundational
set of articles and then used an iterative search strategy
to capture additional relevant literature [11]. Specifically,
we started with a set of 22 prominent articles describing
a range of organizational approaches to health care deliv-
ery systems. To select these articles, we solicited key refer-
ences from experts in the field associated with the AHRQ
Comparative Health System Performance Initiative, with
the goal of including historical and contemporary literature
addressing a range of health care delivery organizational
strategies in the aggregate. This initial list included semi-
nal reviews, taxonomies of health care systems, and origi-
nal studies of various provider organizational structures
(see Appendix A for the list of 22 articles). We then used
a “snowballing” approach to identify other relevant litera-
ture. Specifically, we searched the Scopus database of peer-
reviewed and grey literature to identify additional articles
building from the reference lists of these 22 articles, dating
back to 2007. We then searched Google Scholar to search for
new articles that cited the original 22 articles. We supple-
mented these searches with additional key author searches
and targeted hand searching to fill in gaps on identified
organizational structures for health care delivery systems.

After removing duplicates, three reviewers screened the
titles and abstracts of 1,750 articles for relevance. Articles
were included if they: (1) addressed the U.S. health care
delivery system and (2) focused on characterizing health
care provider organizations and/or health systems. In
total, we analyzed 87 publications for this review. The
full list of reviewed articles is presented in Appendix B.
We used NVivo 11, a software that supports qualitative
analysis, to analyze included texts. Three researchers
developed, tested, and refined a code list to apply to the
literature text. The team coded a shared set of five articles
to ensure coding consistency, then independently coded
the remaining pieces.

Results
The literature identifies a wide variety of U.S. organi-
zational structures and approaches to integrating care
across providers. We group these structures in terms of
horizontal and vertical integration and describe how they
vary in terms of their goals, included providers, and key
features. Table 1 provides a summary of each structure’s
key features. We focus on care management and admin-
istrative oversight, which may influence the nature and
magnitude of integration among included providers.

Horizontally integrated organizational structures
Single specialty group practices. Historically, U.S. phy-
sicians practiced as individual providers in “solo” practice.
Thus, the simplest form of horizontal integration is the
single specialty group practice. These organizations can

Heeringa et al: Horizontal and Vertical Integration of Health Care Providers Art. 2, page 3 of 10

be of varying sizes and are composed of physicians with
a common specialty, although in the modern era of sub-
specialization, related specialties may be aggregated into
one organization. For example, non-invasive cardiologists,
interventional cardiologists, and electrophysiologists
work together in a single specialty cardiology group. Phy-
sicians primarily form single specialty practices to achieve
economies of scale and gain market share, while they may
also be seeking professional management or infrastruc-
ture investments [12, 13]. These practices may also be
owned by hospitals, health plans, or other firms [12].

Independent practice associations. Independent prac-
tice associations (IPAs) are loosely, contractually integrated
networks of independent physicians and physician groups
that are primarily organized to engage in risk-based con-
tracting with payers [12, 14]. IPAs initially emerged in
response to the growth of managed care in the United
States during the 1990s but continue to be a relevant
model in the context of payment reform, as they help
network physicians assume and share financial risk while
also enabling them to maintain their independence [14,
15, 16]. These organizational structures may also provide
infrastructure services and create processes for quality
improvement and care management [12]. As an example,
Hill Physicians Medical Group, one of the largest IPAs in
the United States, contracts with health insurers on behalf
of its large primary care and specialist physician network
[17]. Shortell, Casalino, and Fisher (2010) observed that
many IPAs have evolved over time “into more-organized
networks of practices that are actively engaged in practice
redesign, quality improvement initiatives, and implemen-
tation of electronic health records” [18, p. 1295].

Multispecialty group practices. Multispecialty group
practices (MSGPs) bring together a diverse group of
physicians, including primary and specialty care physi-
cians, “who share common governance, infrastructure,
and finances, and refer patients to one another for ser-
vices offered within the group” [13, p. 2]. Physicians tend
to form these organizations to share governance,
resources, and patients and essentially achieve greater
care coordination [13, 15]. Shortell, Casalino, and Fisher
(2010) noted, “Because they include multiple specialties,
they can provide most care that patients need within the
group…” [15, p. 54]. Because of their scope, MSGPs have
sometimes been described as having “highly developed
mechanisms for providing coordinated clinical care” [18,
p. 1294]. Further, MSGPs, such as the Mayo Clinic, may
have strong affiliations and referral relationships with a
specific local hospital, which may transition into formal
vertical integration relationships [15, 19].

Virtual physician networks. Virtual physician net-
works are less formalized, regional networks intended to
provide infrastructure, care management, care coordina-
tion networks, and other resources to providers to support
the provision of integrated, organized care locally [15, 18,
20]. Often formed to serve rural areas or otherwise under-
served U.S. patient populations, they may be payer- or
provider-driven and are often facilitated by individual pro-
viders, state Medicaid agencies, medical foundations, or
similar organizations [18, 20]. Such networks can serve as

the basis for more substantive integration strategies such
as Medicaid ACOs. For example, Minnesota’s Integrated
Health Partnership’s ACO model includes a virtual model
enabling providers not affiliated with a hospital or IDS
to form virtual networks for the purposes of serving as a
Medicaid ACO [21].

Multihospital systems. Multihospital systems are
characterized by “horizontal integration of facilities…that
provided similar acute care services in multiple locations.”
[22, p. 15]. The University of Pennsylvania Health System,
composed of three hospitals, is an example [23]. Burns
and Pauly (2002) noted that these systems “feature com-
mon asset ownership but separate system versus hospital
boards and executives” [24, p. 131]. These systems emerged
to help hospitals achieve economies of scale and improve
access through an expanded delivery network through
integration of hospitals in the late 1980s to mid-1990s
[4, 24]. However, many evolved into vertically integrated
structures through acquisition of physician practices,
ambulatory centers, and post-acute care providers, among
other entities [4, 15]. Thus, to the extent these systems
also include other care providers, they would be more
appropriately classified as a form of vertical integration.

Vertically integrated organizational structures
Physician-hospital organizations. Physician-hospital
organizations (PHOs), such as Advocate Health System
in Chicago, are a form of physician-hospital integration,
albeit a looser one than certain other models such as med-
ical foundations [14, 15, 24]. PHOs entail a formal partner-
ship between hospitals and all or some of their affiliated
physicians for the purposes of contracting with one or
more health plans [12, 13, 15, 16]. Physicians and hospi-
tals form PHOs to achieve greater alignment while main-
taining autonomy and being governed separately [14, 15,
24]. Indeed, Shortell and colleagues (2014) defined a PHO
as an “organisational form that is less formally integrated
into a system, but is based on alignment across clinicians
and hospitals.” [25, p. 23] Wise and colleagues (2012)
noted that PHOs generally have some form of affiliation
agreement that allows physicians and the hospital(s) to
work cooperatively while being governed independently
[26]. Physicians in these arrangements may share care
management and information technology resources with
other practices [14].

Management services organizations. Management
services organizations (MSO) are entities owned by a hos-
pital or physician-hospital joint venture that purchase
physical assets of participating physicians and provide
administrative services to physicians for a fee [24, 26].
Often grouped with other forms of physician-hospital
integration, MSOs may entail exclusive contracting rela-
tionships between hospitals and physicians [14, 27].
Providers formed these organizations for the purposes of
contracting with health plans and to obtain administra-
tive and infrastructure support [12, 28]. Because MSOs
provide a range of administrative and infrastructure sup-
port services to member physicians, they may play a role
in supporting the provision of certain care management
functions.

Heeringa et al: Horizontal and Vertical Integration of Health Care ProvidersArt. 2, page 4 of 10

Ta
b

le
1

: K
ey

f
ea

tu
re

s
of

t
h

e
h

or
iz

on
ta

ll
y

an
d

v
er

ti
ca

ll
y

in
te

gr
at

ed
s

tr
u

ct
u

re
s.

O
rg

an
iz

at
io

n

ty
p

e
In

cl
u

d
ed

h
ea

lt
h

c
ar

e
p

ro
vi

d
er

s
an

d

se
rv

ic
es

C
ar

e
m

an
ag

em
en

t
fu

n
ct

io
n

s
A

d
m

in
is

tr
at

iv
e

o
ve

rs
ig

h
t

o
f

p
ro

vi
d

er
s

H
o

ri
zo

n
ta

ll
y

in
te

gr
at

ed
s

tr
u

ct
u

re
s

Si
n

gl
e

sp
ec

ia
lt

y
gr

ou
p

p
ra

ct
ic

e
•

Ph
ys

ic
ia

n
s

•
Ph

ys
ic

ia
n

s
er

vi
ce

s
•

V
ar

ie
s

d
ep

en
d

in
g

on
s

p
ec

ia
lt

y
re

p
re

se
n

te
d

•
H

os
p

it
al

s,
h

ea
lt

h
p

la
n

s,
p

h
ys

ic
ia

n
s,

a
n

d
ot

h
er

fi
rm

s
m

ay
o

w
n

or

m
an

ag
e

si
n

gl
e

sp
ec

ia
lt

y
p

ra
ct

ic
es

, w
h

ic
h

c
ou

ld
in

fl
u

en
ce

th

e
de

gr
ee

o
f a

dm
in

is
tr

at
iv

e
ov

er
si

gh
t o

ve
r

in
cl

u
de

d
pr

ov
id

er
s.

M
u

lt
is

p
ec

ia
lt

y
gr

ou
p

p
ra

ct
ic

e
•

Ph
ys

ic
ia

n
s

of
v

ar
io

u
s

sp
ec

ia
lt

ie
s

•
Se

rv
ic

es
v

ar
y

d
ep

en
d

in
g

on
in

cl
u

d
ed

sp

ec
ia

lt
ie

s

•
M

ay
f

ac
il

it
at

e
p

at
ie

n
t

re
fe

rr
al

, i
m

p
ro

ve
c

ar
e

co
or

d
in

at
io

n
, a

n
d

b
e

b
et

te
r-

p
os

it
io

n
ed

t
o

m
an

ag
e

th
e

co
st

s
of

c
ar

e
[1

2
, 1

5
]

•
M

u
lt

is
p

ec
ia

lt
y

gr
ou

p
p

ra
ct

ic
es

s
h

ar
e

go
ve

rn
an

ce
a

n
d

in
fr

a-
st

ru
ct

u
re

, w
h

ic
h

c
an

r
es

u
lt

in
t

ig
h

te
r

m
an

ag
em

en
t

co
n

tr
ol

;
h

ow
ev

er
, c

on
tr

ol
c

an
v

ar
y

de
p

en
di

n
g

on
fa

ct
or

s
su

ch
a

s
si

ze
a

n
d

w
h

et
h

er
t

h
e

p
ra

ct
ic

e
is

p
h

ys
ic

ia
n

-o
w

n
ed

, o
w

n
s

a
h

os
p

it
al

, o
r

is
o

w
n

ed
b

y
h

os
p

it
al

/s
ys

te
m

[1
2

, 1
5

].

In
d

ep
en

d
en

t
p

ra
ct

ic
e

as
so

ci
a-

ti
on

•
Ph

ys
ic

ia
n

s
•

Se
rv

ic
es

v
ar

y
d

ep
en

d
in

g
on

in
cl

u
d

ed

sp
ec

ia
lt

ie
s

•
La

rg
el

y
se

rv
e

co
n

tr
ac

ti
n

g
ro

le
a

n
d

p
ro

vi
d

e
ad

m
in

is
tr

at
iv

e
an

d

co
n

tr
ac

tu
al

f
u

n
ct

io
n

s
[1

5
]

•
M

ay
p

ro
vi

d
e

in
fr

as
tr

u
ct

u
re

s
er

vi
ce

s
to

s
u

p
p

or
t

p
er

fo
rm

an
ce

im
–

p
ro

ve
m

en
t

an
d

c
ar

e
m

an
ag

em
en

t
[2

0
, 3

2
]

•
M

ay
p

ro
vi

d
e

p
ro

ce
ss

es
a

n
d

r
es

ou
rc

es
t

o
su

p
p

or
t

ca
re

m
an

ag
e-

m
en

t
su

ch
a

s
d

is
ea

se
r

eg
is

tr
ie

s,
n

u
rs

e
ca

re
m

an
ag

er
s,

e
tc

. [
14

]

•
Ph

ys
ic

ia
n

s
m

ai
n

ta
in

in
d

ep
en

d
en

t
ow

n
er

sh
ip

a
n

d
m

an
ag

e-
m

en
t

of
p

ra
ct

ic
es

, w
h

il
e

th
e

in
d

ep
en

d
en

t
p

ra
ct

ic
e

as
so

ci
a-

ti
on

p
ri

m
ar

il
y

n
eg

ot
ia

te
s

co
n

tr
ac

ts
w

it
h

h
ea

lt
h

p
la

n
s

[1
6

,
4

0
].

V
ir

tu
al

p
h

ys
i-

ci
an

n
et

w
or

ks

•
Ph

ys
ic

ia
n

s
•

Se
rv

ic
es

v
ar

y
d

ep
en

d
in

g
on

in
cl

u
d

ed

sp
ec

ia
lt

ie
s

•
En

ti
ti

es
t

h
at

o
rg

an
iz

e
th

es
e

n
et

w
or

ks
, s

u
ch

a
s

m
ed

ic
al

f
ou

n
d

a-
ti

on
s

or
s

ta
te

M
ed

ic
ai

d
a

ge
n

ci
es

, m
ay

p
ro

vi
d

e
ca

re
c

oo
rd

in
at

io
n

n

et
w

or
ks

; c
er

ta
in

in
fr

as
tr

u
ct

u
re

r
es

ou
rc

es
, s

u
ch

a
s

h
ea

lt
h

in
fo

r-
m

at
io

n
t

ec
h

n
ol

og
y

an
d

in
fo

rm
at

io
n

e
xc

h
an

ge
; a

n
d

c
ar

e
m

an
ag

e-
m

en
t

se
rv

ic
es

t
o

m
em

b
er

p
h

ys
ic

ia
n

s,
w

h
o

in
t

u
rn

c
ou

ld
u

se
t

h
os

e
se

rv
ic

es
in

t
h

e
p

ro
vi

si
on

o
f

ca
re

[
15

, 1
8

, 2
0

]

•
Th

es
e

n
et

w
or

ks
t

en
d

t
o

b
e

ch
ar

ac
te

ri
ze

d
b

y
le

ss
f

or
m

al

b
u

re
au

cr
at

ic
c

on
tr

ol
[

15
].

M
u

lt
ih

os
p

it
al

sy

st
em

s
•

Tw
o

or
m

or
e

h
os

p
it

al
s

•
Pr

im
ar

il
y

h
os

p
it

al
s

er
vi

ce
s,

w
h

ic
h

m
ay

in

cl
u

d
e

in
p

at
ie

n
t

an
d

a
m

b
u

la
to

ry

se
rv

ic
es

•
V

ar
ie

s
d

ep
en

d
in

g
on

in
cl

u
d

ed
s

er
vi

ce
; i

n
v

er
ti

ca
ll

y
in

te
gr

at
ed

m

od
el

s,
m

u
lt

ih
os

p
it

al
s

ys
te

m
s

m
ay

h
av

e
ca

re
f

u
n

ct
io

n
s

th
at

a

m
or

e
an

al
og

ou
s

to
in

te
gr

at
ed

d
el

iv
er

y
sy

st
em

s.

•
A

s
m

u
lt

ih
os

p
it

al
s

ys
te

m
s

ar
e

ch
ar

ac
te

ri
ze

d
by

s
h

ar
ed

o
w

n
er

–
sh

ip
o

r
m

an
ag

em
en

t,
ad

m
in

is
tr

at
io

n
m

ay
h

av
e

m
or

e
di

re
ct

co

n
tr

ol
o

ve
r

in
cl

u
de

d
h

os
p

it
al

s,
in

cl
u

di
n

g
ca

re
p

ro
ce

ss
es

,
sh

ar
ed

o
rg

an
iz

at
io

n
al

m
is

si
on

s,
a

n
d

th
e

lik
e.

H
ow

ev
er

, t
h

ey

m
ay

a
ls

o
m

ai
n

ta
in

s
ep

ar
at

e
h

os
p

it
al

b
oa

rd
s

an
d

ex
ec

u
ti

ve
s,

de

sp
it

e
sh

ar
ed

a
ss

et
o

w
n

er
sh

ip
[2

4]
.

V
er

ti
ca

ll
y

in
te

gr
at

ed
s

tr
u

ct
u

re
s

Ph
ys

ic
ia

n
h

os
p

i-
ta

l o
rg

an
iz

at
io

n

•

H
os

p
it

al
s

an
d

th
ei

r
af

fi
lia

te
d

p
h

ys
ic

ia
n

s
•

H
os

p
it

al
s

an
d

p
h

ys
ic

ia
n

s
er

vi
ce

s,
w

h
ic

h

va
ry

d
ep

en
d

in
g

on
in

cl
u

d
ed

s
p

ec
ia

lt
ie

s

•
Fa

ci
li

ta
te

m
an

ag
ed

c
ar

e
co

n
tr

ac
ti

n
g,

p
ro

vi
d

e
ad

m
in

is
tr

at
iv

e
se

rv
ic

es
t

o
p

h
ys

ic
ia

n
s,

f
ac

il
it

at
e

n
at

u
ra

l r
ef

er
ra

l r
el

at
io

n
sh

ip
s

ar
ou

n
d

o
n

e
h

os
p

it
al

, a
n

d
m

an
ag

e
am

b
u

la
to

ry
c

ar
e

fa
ci

li
ti

es
w

h
er

e
p

h
ys

ic
ia

n
s

w
or

k
[1

5
, 2

8
]

•
Ph

ys
ic

ia
n

s
m

ai
n

ta
in

in
d

ep
en

d
en

t
ow

n
er

sh
ip

a
n

d
m

an
ag

e-
m

en
t

of
p

ra
ct

ic
es

, w
h

il
e

p
ra

ct
ic

es
c

on
tr

ac
t

w
it

h
h

ea
lt

h

p
la

n
s

th
ro

u
gh

t
h

e
or

ga
n

iz
at

io
n

[
18

, 2
8

].

•
C

lo
se

d
p

h
ys

ic
ia

n
-h

os
p

it
al

o
rg

an
iz

at
io

n
s

se
le

ct
iv

el
y

co
n

tr
ac

t
w

it
h

p

h
ys

ic
ia

n
s

on
t

h
e

b
as

is
o

f
qu

al
it

y
an

d
co

st
p

er
fo

rm
an

ce
a

n
d

h
av

e
ex

cl
u

si
ve

r
el

at
io

n
sh

ip
s

w
it

h
p

h
ys

ic
ia

n
s

an
d

cl
os

e
re

la
ti

on
sh

ip
s

w
it

h

h
os

p
it

al
s,

w
h

ic
h

m
ay

f
ac

ili
ta

te
c

ar
e

co
or

di
n

at
io

n
[2

8
]

•
M

ay
p

ro
vi

de
p

ro
ce

ss
es

a
n

d
re

so
u

rc
es

to
s

u
pp

or
t c

ar
e

m
an

ag
em

en
t [

14
]

(C
on

td
.)

Heeringa et al: Horizontal and Vertical Integration of Health Care Providers Art. 2, page 5 of 10

O
rg

an
iz

at
io

n

ty
p

e
In

cl
u

d
ed

h
ea

lt
h

c
ar

e
p

ro
vi

d
er

s
an

d

se
rv

ic
es

C
ar

e
m

an
ag

em
en

t
fu

n
ct

io
n

s
A

d
m

in
is

tr
at

iv
e

o
ve

rs
ig

h
t

o
f

p
ro

vi
d

er
s

M
an

ag
em

en
t

se
rv

ic
es

o
rg

an
i-

za
ti

on

•
Ph

ys
ic

ia
n

s
an

d
h

os
p

it
al

s
if

h
os

p
it

al
s

ar
e

th
e

ow
n

er
s

of
t

h
e

or
ga

n
iz

at
io

n
•

Th
es

e
or

ga
n

iz
at

io
n

s
p

ro
vi

d
e

ad
m

in
is

tr
at

iv
e

an
d

in
fr

as
tr

u
ct

u
re

se

rv
ic

es
, w

h
ic

h
m

ay
in

cl
u

d
e

ca
re

c
oo

rd
in

at
io

n
, c

ar
e

m
an

ag
em

en
t

se
rv

ic
es

a
n

d
h

ea
lt

h
in

fo
rm

at
io

n
t

ec
h

n
ol

og
y,

t
o

p
h

ys
ic

ia
n

m
em

–
b

er
s

[1
2

, 2
7,

2
8

]

•
M

an
ag

em
en

t
se

rv
ic

es
o

rg
an

iz
at

io
n

s
p

ro
vi

d
e

se
rv

ic
es

t
o

m
em

b
er

p
h

ys
ic

ia
n

s
an

d
c

on
tr

ac
t

w
it

h
p

ay
er

s
on

b
eh

al
f

of
m

em
b

er
p

ro
vi

d
er

s;
h

ow
ev

er
, p

ro
vi

d
er

s
la

rg
el

y
re

ta
in

in

d
ep

en
d

en
ce

.

C
li

n
ic

al
ly

in
te

–
gr

at
ed

n
et

w
or

k
•

Pr
im

ar
il

y
in

cl
u

d
e

p
h

ys
ic

ia
n

s
b

u
t

m
ay

al

so
in

cl
u

d
e

h
os

p
it

al
s

an
d

o
th

er
p

ro
vi

d
–

er
s

su
ch

a
s

p
os

t-
ac

u
te

c
ar

e
p

ro
vi

d
er

s.

•
Se

rv
ic

es
v

ar
y

d
ep

en
d

in
g

on
n

et
w

or
k

co
m

p
os

it
io

n
.

•
Pr

ov
id

er
s

se
ek

in
g

to
f

or
m

t
h

es
e

n
et

w
or

ks
m

u
st

d
em

on
st

ra
te

in

te
gr

at
io

n
c

li
n

ic
al

ly
t

h
ro

u
gh

a
n

u
m

b
er

o
f

ac
ti

vi
ti

es
, i

n
cl

u
d

in
g

im
p

le
m

en
ta

ti
on

o
f

a
p

ro
gr

am
t

o
ev

al
u

at
e

an
d

m
od

if
y

p
ra

ct
ic

e
p

at
te

rn
s

an
d

c
re

at
io

n
o

f
a

h
ig

h
d

eg
re

e
of

in
te

rd
ep

en
d

en
ce

a
n

d
c

o-
op

er
at

io
n

a
m

on
g

n
et

w
or

k
p

h
ys

ic
ia

n
s

to
c

on
tr

ol
c

os
ts

a
n

d
e

n
su

re

qu
al

it
y.

•

Ex
am

p
le

f
ea

tu
re

s
of

p
ro

gr
am

s
in

cl
u

d
e:

◦
Im

p
le

m
en

ti
n

g
sy

st
em

s
to

e
n

su
re

a
p

p
ro

p
ri

at
e

u
ti

li
za

ti
on

of

s
er

vi
ce

s
◦
D

ep
lo

yi
n

g
ev

id
en

ce
-b

as
ed

p
ra

ct
ic

e
st

an
da

rd
s

an
d

p
ro

to
co

ls

◦
Pe

rf
or

m
an

ce
e

va
lu

at
io

n
a

n
d

fe
ed

b
ac

k
to

in
cl

u
de

d
p

ro
vi

de
rs

◦
C

as
e

m
an

ag
em

en
t

an
d

c
ar

e
co

or
d

in
at

io
n

[
2

9
, 3

0
]

•
Pr

ov
id

er
s

ar
e

ei
th

er
in

te
gr

at
ed

v
ia

o
w

n
er

sh
ip

o
r

co
n

tr
ac

–
tu

al
r

el
at

io
n

sh
ip

s;
t

h
e

cl
in

ic
al

in
te

gr
at

io
n

f
ra

m
ew

or
k

re
qu

ir
es

p
h

ys
ic

ia
n

s
to

u
se

c
on

si
st

en
t

ca
re

p
ro

to
co

ls
a

n
d

t
o

m
on

it
or

q
u

al
it

y,
s

u
gg

es
ti

n
g

gr
ea

te
r

ov
er

si
gh

t
an

d
m

an
ag

e-
m

en
t

of
in

cl
u

d
ed

p
ro

vi
d

er
s

[2
9

, 3
0

].

Fo
u

n
d

at
io

n

m
od

el

•
V

ar
ie

s;
p

ri
m

ar
il

y
li

m
it

ed
t

o
p

h
ys

ic
ia

n
s;

h

ow
ev

er
, i

n
s

om
e

st
at

es
w

it
h

c
or

p
or

at
e

p
ra

ct
ic

e
of

m
ed

ic
in

e
la

w
s,

c
er

ta
in

h
os

–
p

it
al

s
su

ch
a

s
n

on
p

ro
fi

t
h

ea
lt

h
c

or
p

or
a-

ti
on

s
or

f
ed

er
al

ly
q

u
al

if
ie

d
h

ea
lt

h
c

en
t-

er
s,

m
ay

e
m

p
lo

y
p

h
ys

ic
ia

n
s,

p
ro

vi
d

ed

p
h

ys
ic

ia
n

a
u

to
n

om
y

is
m

ai
n

ta
in

ed
[

3
3

].
•

Ph
ys

ic
ia

n
s

er
vi

ce
s

ar
e

ex
p

li
ci

tl
y

in
–

cl
u

d
ed

, b
u

t
th

es
e

st
ru

ct
u

re
s

ar
e

of
te

n

fo
rm

ed
t

o
fa

ci
li

ta
te

c
ol

la
b

or
at

io
n

b
e-

tw
ee

n
h

os
p

it
al

s
an

d
p

h
ys

ic
ia

n
s

[2
8

, 3
3

].

•
V

ar
ie

s;
m

ay
h

av
e

fu
n

ct
io

n
s

si
m

il
ar

t
o

in
te

gr
at

ed
d

el
iv

er
y

sy
st

em
s

in
m

od
el

s
w

h
er

e
th

e
p

h
ys

ic
ia

n
o

rg
an

iz
at

io
n

a
n

d
h

os
p

it
al

h
av

e
m

u
tu

al
ly

e
xc

lu
si

ve
c

on
tr

ac
ti

n
g

re
la

ti
on

sh
ip

s
[3

1
]

•
A

k
ey

f
ea

tu
re

o
f

th
is

m
od

el
is

t
h

e
sa

la
ri

ed
e

m
p

lo
ym

en
t

of
p

h
ys

ic
ia

n
s

b
y

a
n

on
-p

ro
fi

t
en

ti
ty

; w
h

il
e

em
p

lo
ym

en
t

m
ay

s
u

gg
es

t
gr

ea
te

r …