Project Summary/Abstract
Integrated delivery systems are becoming increasingly important due to increasing trends toward consolidation
in the midst of rapidly expanding health care reform efforts enacted by the Affordable Care Act. Enormous
variation exists across delivery systems in terms of their organizational characteristics and operations.
However, little knowledge exists regarding how or why quality of care varies or how individual measures
correlate at this level due to a lack of systematically collected data regarding health system affiliations, system
characteristics or their use of internal mechanisms to further quality goals. This study, therefore, addresses
significant gaps in the literature with three aims: (1) study variation in quality performance across provider
levels, (2) study the association between system characteristics and quality performance, and (3) study the
relationship between quality improvement activities and quality. The study relies on advanced empirical
methods and uses several unique data sets including individual-level care experiences and adherence to care
processes for Fee-for-service Medicare enrollees, and a new, comprehensive, national-level dataset on U.S.
health systems and a nationally representative survey on organizational operations including its use of specific
mechanisms to improve the effectiveness and efficiency of health care delivery. I will employ hierarchical linear
modeling (HLM) to study aims 1 and 2. For Aim 1, random intercepts for system and practice identifiers are
used to assess variation within and across delivery systems. To understand the extent to which systems differ
in their ability to care for different patient groups, random slopes for patient covariates will be added to models.
To study Aim 2, I use HLMs with a random intercept for the system and fixed effects for the system attributes
to determine the extent to which structural features of the organizational are associated with better or worse
care. For Aim 3, I employ a doubly-robust method to evaluate the impact of using financial and non-financial
incentive mechanisms on quality outcomes.