|
Items in cart [0] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 402
For-Profit Enterpnse in Health Care. 1~6.
Nabonal Academy Press, Washington, D.C.
Physician Participation in the Adniinistra~don and
Governance of System and Freestanding Hospices:
A Comparison by Type of Ownership
Jeffrey A. Alexander, Michael A. Mornsey,
and Stephen M. Shortell
INTRODUCTION
This paper examines the type and extent of
physician participation in the administration
and governance of hospitals in multihospital
systems. Particular emphasis is given to phy-
sician participation in investor-owned chain
hospitals relative to freestanding hospitals and
other system-affiliated institutions.
The advent of prospective pricing, coupled
with the rise of multi-institutional arrange-
ments in the hospital industry is thought to
have major implications for the role ofthe phy-
sician in the hospital. The nature of many of
these changes, however, is still open to em-
pirical question. Brown (1979) and Reynolds
and Studen (1978) suggest that hospital con-
solidation into systems may promote more for-
malizec] methods for securing physician input
into hospital decision-making processes.22
Others have argued, however, that physician
power and influence in hospital policymaking
and administration will be reduced in the con-
text of multi-institutional arrangements and the
"corporatization" of medicine.34
Physician involvement in hospital decision
making represents a potentially important is-
sue for several reasons. First, several national
groups (i.e., American Hospital Association
[AHA], loins Commission on Accreditation of
Hospitals MICAH], American Medical Associ-
ation [AMA]) perceive and endorse physician
Dr. Morrisey is in the Department of Health Care
Organization and Policy and Dr. Alexander is in the
Department of Health Services Administration, both
at the University of Alabama at Birmingham. When
this paper was written they were with the Hospital
Research and Educational Trust, Chicago, Illinois. Dr.
Shortell is with the J. L. Kellogg Graduate School of
Management and Center for Health Services and Pol-
icy Research at Northwestern University, Evanston,
Illinois.
402
participation in hospital decision making as an
important mechanism for conflict resolution
among the administration, board members, and
medical staff.5 Second, such participation is
seen to foster an institution-wide perspective
among medical staff members, of particular
importance under diagnosis-related group
(DRG) reimbursement. Finally, studies by
Neuhauser (1971), Shortell et al. (1976), Shor-
tel1 and LoGerfo (1981), and Morlock et al.
(1979) suggest that greater medical staff par-
ticipation in governance is associated with
higher quality hospital care.6~9
In light of the above, this study examines a
series of structural variables related to physi-
cian involvement in hospital decision making.
Two categories of involvement are considered:
(~) physician participation in hospital gover-
nance, and (2) physician participation in hos-
pital management.
The primary group under investigation are
those hospitals owned or leased by investor-
owned multihospital systems (IO hospitals). On
a series of physician decision-making vari-
ables, these hospitals are compared to five other
hospital groups: (1) freestanding hospitals or
those not affiliated with a multihospital sys-
tem; (2) hospitals owned or leased, by secular
nonprofit multihospital systems; (3) hospitals
owned, leased, or sponsored by religious mul-
tihospital systems; (4) hospitals owned or leased
by public multihospital systems; and (5) hos-
pitals contract-managed by all of the afore-
mentioned system types.
SAMPLE
The sample for this study was composed of
3,027 community hospitals located in the 48
contiguous states and the District of Colum-
bia. The sample hospitals were chosen by ran-
dom selection and represent 25 percent of all
OCR for page 403
PHYSICIAN PARTICIPATION IN GOVERNANCE
community hospitals, augmented with addi-
tional, randomly selected hospitals in 22 states.
These states were primarily those with man-
datory or voluntary rate review programs.
Sample hospitals were sent a six-page sur-
vey questionnaire related to medical staff or-
ganization. Of the 3,027 sample hospitals, 2,065
responded to the survey, a response rate of
69.9 percent. These hospitals represented the
final sample for this investigation.
It is important to note that the hospitals in
this study are not representative of all com-
munity hospitals insofar as sample represen-
tation was greater for New England, Middle
Atlantic, and West North Central regions than
for the South East, East South Central, and
West South Central regions. Sample hospitals
were also more likely to be involved in teach-
ing activities and less likely to be investor-
owned than the population of community hos-
pitals.~°
DATA
Data for this investigation were obtained from
these sources: (1) the 1982 AHA Survey of
Hospital Medical Staffs; (2) the 1982 AHA An-
nual Survey of Hospitals; and (3) the 1982 AHA
Validation Survey of Multihospital Systems.
The medical staff survey provided information
on the type and extent of physician/medical
participation in hospital decision making. The
annual survey was used to obtain data on se-
lected hospital characteristics (e.g., size,
teaching involvement, and regional location).
The validation survey indicated whether or not
a hospital was part of a multihospital system,
the ownership status of that system and the
type of hospital affiliation with the system (i.e.,
owned, leased, sponsored, or contract-man-
aged).
MEASUREMENT
Physician participation in hospital gover-
nance was measured by four variables: (1) total
number of physician members on the hospital
governing board; (2) whether or not physician
board members have voting privileges; (3)
whether or not physicians serve on the board
executive committee and; (4) whether or not
the hospital chief executive officer (CEO) is a
voting member of the hospital governing board.
403
The latter item, while not a direct indicator of
physician involvement on the board, is indic-
ative of participation and influence by the ad-
ministrative component ofthe hospital, possibly
complementing physician influence.
Physician involvement in hospital manage-
ment activity was assessed by six variables: (1)
whether or not any staff physicians hold salar-
ied positions as part of the hospital's manage-
ment team; (2) whether or not the chief of the
hospital medical staff is compensated by the
hospital; (3) whether or not the director of
medical education is compensated by the hos-
pital; (4) whether or not the hospital has a
medical staff committee for long-range plan-
ning; (5) whether or not the hospital has a
medical staff committee for cost containment/
cost awareness; and (6) the total number of
medical staff committees in the hospital.
Because many of the outcome measures de-
scribed above may be influenced by factors
other than multihospital system participation,
several control variables were incorporated in
the analysis. These included hospital size as
measured by the total number of beds set up
and staffed for use; regional location of hos-
pital, indicated by whether the hospital is sit-
uated in the Northeast, South, North Central,
or Western areas of the country; size of stan-
dard metropolitan statistical area (SMSA),
measured by seven population categories
ranging from 0 to over 2.5 million; teaching
involvement, assessed by the number of house
staff in the hospital; and system size as indi-
cated by the number of owned, leased, spon-
sored, or managed hospitals in the system.
Hospitals not affiliated with a system were as-
signed a value of 0 on this variable.
Descriptive statistics for the dependent, in-
dependent, and control variables are pre-
sented in Table 1.
ANALYTIC APPROACH
Zero-order comparisons among investor-
owned and other hospital categories were per-
formed using chi-square tests of significance
in the case of dichotomous variables, and d~f-
ference-of-means l-tests in the case of contin-
uous, dependent variables. IO hospitals were
compared separately to each of the other five
hospital categories.
Following zero-order comparisons, all de
OCR for page 404
404
FOR-PROFIT ENTER[FUSE IN HEALTH CARE
CABIN 1 Descriptive Statistics for Hospital Sample
(N = 2,067)
Vanables
Standard Number
Mean Deviation in Samplea
. .. .
Independent Variables
Freestanding hospital.71.45 1,469
System characteristics
System control
Religious nonprofit.12.32 247
Secular nonprofit.03.18 70
Investor-owned.06.24 126
Public.01.07 11
Contract-managed.07.25 144
System size21.0072.28
Hospital characteristics
Number of beds190.76179.53
Regional location
Northeast.23.42 468
South.26.44 542
Norm Central.32.47 660
West.19.39 397
SMSA sizes
Non-SMSA.45.50 929
Under 100,000.02.12 32
100,000-250,000.09.28 178
250,000-500,000.09.29 187
500,000-1 million.08.27 160
1 million-2.5 million.14.35 297
Over 2.5 million.14.34 284
House staff11.6050.14
Dependent Variables
Whether M.D.s receive salaries as
administrators.16
Whether director of medical education paid.19
Whether chief of staff paid
Whether chief executive officer is voting
member of governing board
Whether M.D.s on governing board of
executive committee
Whether M. D. governing board members
have voting rights
Whether hospital has committee for cost
containment/awareness
Whether hospital has committee for medical
staff long-range planning
.36
.39
.07 .26
34
.
.35
.47
.48
323
392
145
697
720
.70 .46 1,437
.16
.37
.28 .45
329
584
a For dichotomously scored variables only.
bSize of standard metropolitan statistical area (SMSA).
OCR for page 405
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE 2 Comparison of Hospitals in For-profit Systems with Other Hospital TvDes
Number of Physicians on Governing Boards
.
, ~
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
_
Mean Mean Mean Mean Mean Mean
N (S.D.) ~(S.D.) N (S.D.) N (S.D.) N (S.D.) N (S.D.)
125 3.83 1,442
(2.32)
.86*** 24
2. 12)
1.76*** 68
(1.66)
2. 13*** 7
(1.95)
. . _ . _ _ _
**AT significant at p c .01 when compared with hospitals in for-profit systems.
**T significant at p c .05 when compared win hospitals in for-profit systems.
pendent variables were subjected to multi-
variate analysis to assess the impact of hospital
and environmental controls on the bivariate
relationships. Two regressions were per-
formed for each dependent variable. The first
compared all system categories to freestanding
hospitals. The second compared IO system
hospitals to all other system categories and
freestanding hospitals. In the case of dichoto-
mous depenclent variables, multiple logistic
regression was performed. Ordinary least-
squares regression was used for continuous de-
pendent variables.
RESULTS OF COMPARISONS
Governance
Results of the zero-order comparisons be-
tween IO hospitals and other hospital CLOUDS
are presented in Tables 2-11. Results of the
multivariate analysis are contained in the ap-
pendix. In general, our findings suggest that
TABLE 3 Comparison of Hospitals in For-profit Systems with Other Hospital Types: Do
Hospital Physician Governing Board Members Have Voting Privileges?
Yes
No
Total
405
7.00** 142 ~ 42~*'
(14.~) (1.77)
physician participation in hospital governance
is greater in IO hospitals than in the five com-
parison groups. Table 2 indicates that with the
exception of public system hospitals, IO hos-
pitals have on average a greater number of
physicians (X = 3.83) serving on their boards
than the other system hospital groups or free-
standing hospitals. These results are main-
tained even after the introduction of controls
for system size, hospital size, region, SMSA
size, and teaching involvement.
It is important to note that these board po-
sitions can y some influence insofar as 91 per-
cent of the sample IO hospitals indicated that
physician board members had voting privi-
leges on the board (Table 3~. Zero-order com-
parisons between IO hospitals and over groups
also suggest that physician board members are
more likely to have voting privileges in IO
hospitals than in the other five hospital groups.
With the introduction of the control variables,
however, only differences between the IO and
He secular nonprofit and public system hos-
pitals are sustained.
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
Response NMeanNMean NMean ~ Mean N Mean NMean
. .
. _
115 91.27 991 67.46 193 78.14 5071.43 545.45 83 57.64
11 8.73 478 32.54*** 54 21.86*** 2028.57*** 654.55*** 61 42.36***
126 100.040 1,469 100.00 . 247 100.00 70100.00 11100.00 144 100.00
_ . .
$**Chi-square significant at p c .01 when compared with hospitals in for-profit systems.
OCR for page 406
406
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE 4 Comparison of Hospitals in For-profit Systems ninth Other Hospital Types: Are
There Physicians on the Hospital Governing Board Executive Committee?
Hospitals in
For-profit
Systems
Freestanding
Hospitals
Hospitals in
Religious
Systems
Response N % N % N %
Yes
No
Total
Hospitals in
Nonprofit
Systems
N %
Hospitals
in Public
Systems
N %
Contract-
Managed
N %
57 45.24 524 35.67 65 26.32 22 31.43 4 36.36 4833.33
69 54.76 945 64.33** 182 73.68*** 48 68.57* 7 68.64 9666.67*
126 100.00 1,469 100.00 247 100.00 70 100.00 11 100.00 144100.00
***Chi-square significant at p ' .01 when compared with hospitals in for-profit systems.
**Chi-square significant at p c too when compared with hospitals in for-profit systems.
*Chi-square significant at p c .10 when compared with hospitals in for-profit systems.
Table 4 suggests that physicians are more
likely to be members of the important board
executive committee in IO hospitals relative
to all other hospital groups except public sys-
tem hospitals. However, only the difference
between IO hospitals and religious system
hospitals holds after the introduction of the
condos variables. Finally, Table 5 indicates
strong involvement of IO hospital CEOs in
hospital governance. Eighty percent of the
sample IO hospital CEOs participated as vot-
ing members of their governing boards. This
finding is particularly striking when compared
to the low percentage of CEO board mem-
bership in freestanding hospitals (26 percent),
secular nonprofit system hospitals (31 per-
cent), and public system hospitals (9 percent).
As the percentage differences would indicate,
these IO hospital CEOs are significantly more
likely to be members of their hospital govern-
ing board than the CEOs of the other five
hospital groups. The introduction of hospital
and environmental controls does not alter these
differences.
Management
Comparisons related to physician involve-
ment in hospital management suggest a pat-
tern of results opposite that of physician
participation in hospital governance. In gen-
eral, physicians in IO hospitals appear to be
less integrated into hospital managerial activ-
ities than physicians in other hospital catego-
nes.
Table 6, for example, indicates that physi-
cians in IO hospitals are significantly less likely
to hold salaried positions as part of the hos-
pital's administrative team. Only 2 percent of
the IO hospitals in the sample indicated that
their physicians held such positions, by far the
TABLE 5 Comparison of Hospitals in For-profit Systems win Other Hospital Types: Is
the Hospice CEO a Voting Member of the Governing Board?
.
Hospitals in
For-profit Freestanding
Systems Hospitals
Hospitals in
Religious
Systems
Hospitals in Hospitals in
Nonprofit Public Contract
Systems Systems Managed
Response N % N % N % N % N % N %
Yes
No
Total
101 80.1638526.21
25 19.841,08473.79***
126 100.001,469100.00
162 65.59 22 31.43 1 9.09 2618.06
85 34.41*** 48 68.57*** 10 90.91*** 11881.94***
247 100.00 70 100.00 11 100.00 144100.00
***Chi-square significant at p ' .01 when compared with hospitals in for-profit systems.
OCR for page 407
PHYSICIAN PARTICIPATION IN GOVERNANCE
407
TABLE 6 Comparison of Hospitals in For-profit Systems with Other Hospital Types: Do
Physicians lIold Salaried Positions as Part of Hospital's Administrative Team?
. .
Hospitals in Hospitals In Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
Response N % N % N % N % N % N %
Yes 3 2.38 230 15.66 52 21.05 20 28.57 5 45.45 13 9.03
No 123 97.62 1,239 84.34*** 195 78.95*** 50 71.43*** 6 54.55*** 131 90.97**
Total 126 100.00 1,469 100.00 247 100.00 70 100.00 11 100.00 144 100.00
***Chi-square significant at p c .01 when compared with hospitals in for-profit systems.
**Chi-square significant at p 5 .05 when compared with hospitals in for-profit systems.
lowest proportional representation among the
six hospital groups. These finclings remain un-
altered, holding constant the five hospital and
environmental control variables. Consistent
with these findings, key medical staff officers
in IO hospitals are also less likely to be com-
pensated by the hospital (see Tables 7 and 81.
Specifically, chiefs of staff and directors of
medical education in IO hospitals are signifi-
cantly less likely than those in all comparison
groups, except contract-managed hospitals, to
be paid by the hospital.
It should be noteil, however, that when hos-
pital and environmental variables are held
constant, chiefs of staffin IO hospitals are less
likely than those in secular nonprofit system
hospitals to be compensated. Medical educa-
tion directors in IO hospitals are less likely
than their counterparts in freestanding hos-
pitals and religious system hospitals to be com-
pensated after introducing-~e control variables.
A second arena of administrative activity for
physicians is reflected in the medical staffcom-
mittee structure of the hospital. Table 9 sug-
gests that with an average of 11, IO hospitals
have fewer medical staff committees than all
comparison groups except contract-managed
hospitals. These differences, with the excep-
tion of hospitals in secular nonprofit systems,
hold even after controlling for other hospital
and environmental characteristics.
We also examined the presence or absence
of two medical staficommittees that have par-
ticular relevance for hospital administration:
cost containment/awareness anil long-range
planning. IO hospitals appear to be signifi-
cantly less likely to have medical staff com-
mittees on long-range planning (Table 10)
relative to all other groups except public sys-
tem and contract-managed hospitals. Few sig-
nificant differences were obtained between IO
hospitals and other hospital groups on the
presence of a cost containmentlawareness
committee (Table 111. These differences are
TABLE 7 Comparison of Hospitals in For-profit Systems wig Other Hospital Types: Is
Hospital Chief of Staff Compensated?
. . .
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
.
Response N % N % N % N % N % N %
Yes
No
Total 126 100.00 1,469 100.00
2 1.59103
124 98.411,366
7.01 208.10 13
92.99** ~791.90** 57 ~
247100.00 70 100.00
18.57
R1 ***
218.185 3.47
981.82**139 96.53
11100.00144 100.00
***Chi-square significant at p ' .01 when compared with hospitals in for-profit systems.
**Chi-square significant at p < .05 when compared with hospitals in for-profit systems.
OCR for page 408
408
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE 8 Comparison of Hospitals in For-profit Systems win Other Hospital Types: Is
Me Director of Medical Education Compensated?
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
Response N % N To N % N % N % N %
Yes
No
Total 126 100.00 1,469 100.00
9 7.14286
117 92.861,183
19.47 67 27.13 16
80.53*** 180 72.87*** 54 . ~=
247 100.00 70 100.00
22.86
77 1 A***
***Chi-square significant at p c .01 when compared with hospitals in for-profit systems.
eliminated with the introduction of the control
variable set.
Summary
In summary, IO hospitals, relative to free-
standing hospitals, appear to have greater phy-
sician representation on hospital governing
boards although these physicians are no more
or less likely to have voting privileges or to
serve on the board executive committee than
physicians on freestanding hospital boards.
Relative to hospitals in other system cate-
gories, IO hospitals also have greater physician
representation on hospital governing boards.
Only hospitals in public systems have a higher
mean number of physicians on the board. In
addition, physician board members of IO hos-
pitals are more likely to have voting privileges
than those in secular nonprofit and public sys-
tems and are more likely to serve on the ex-
ecutive committee of the board relative to
physicians in religious system hospitals.
545.459 6.25
654.55***135 93.75
11100.00144 100.00
It is important to note that CEOs of IO hos-
pitals are more likely than those in freestand-
ing hospitals to be voting members of the
hospital board. This may suggest a more in-
fluential position of the IO hospital CEO on
the board relative to physicians since no dif-
ferences were obtained between IO hospitals
and freestanding hospitals on physician voting
. .
pI.lVl. Ages.
This same pattern holds when comparing IO
hospitals win hospitals in over system groups.
IO hospitals tend to be significantly more likely
to have Heir CEOs serve as voting members
of the board than hospitals in religious, sec-
ular, nonprofit, or public systems.
In terms of physician involvement in hos-
pital a~ninistra~on, IO hospitals are less likely
to have physicians as salaried administrators
and to have fewer medical staff committees
than freestanding hospitals. When controlling
for other hospital and environmental attri-
butes, however, no significant differences were
obtained between IO and Freestanding hos
TABLE 9 Comparison of Hospitals in For-profit Systems with Other Hospital Types:
Number of Medical StaE Committees
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
Mean Mean Mean Mean Mean Mean
N (S.D.) N (S.D.) N (S.D.) ~ (S.D.) N (S.D.) N(S.D.)
125 11. 14 1,442 13.55*** 241 15.97*** 68 14.06** 7 16.29* 1429.68*
(6.26) (9.36) (8.70) (10.89) (6.58) (6.96)
***T significant at p s .01 when compared with hospitals in for-profit systems.
**T significant at p s .05 when compared with hospitals in for-profit systems.
*T significant at p ' .10 when compared with hospitals in for-profit systems.
OCR for page 409
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE 10 Comparison of Hospitals in For-profit Systems with Other Hospital Types:
Does He Hospital Have a Committee for Medical Staff Long-Range Planning?
409
Hospitals in Hospitals in Hospitals in Hospitals
For-profit Freestanding Religious Nonprofit in Public Contract
Systems Hospitals Systems Systems Systems Managed
Response N % N % N % N % N % N %
Yes 19 15.08 436 29.68 77 31.17 22 31.43 3 27.27 27 18.75
No 107 84.92 1,033 70.32*** 170 68.83*** 48 68.57*** 8 72.73 117 81.25
Total 126 100.00 1,469 100.00 247 100.00 70 100.00 11 100.00 144 100.00
***Chi-square significant at p s .01 when compared with hospitals in for-profit systems.
pitals on compensation for key medical staff
members or the existence of a medical staff
committee on cost containment/awareness.
However, IO hospitals are less likely than free-
standing hospitals to have a medical staEcom-
mittee on long-range planning.
In general, comparisons of IO hospitals with
other system groups on variables related to
administrative involvement vaned by com-
parison groups. For example, IO hospitals were
less likely to compensate their chief of medical
stallonly relative to secular nonprofit hospitals
and less likely to compensate their director of
medical education when compared to religious
system hospitals. However, IO hospitals, rel-
ative to all other system types, were less likely
to have physicians salaried as part of the hos-
pital's administrative team.
DISCUSSION AND TRIPLICATIONS
The findings on physician involvement in
hospital management and governance are of
interest primarily in terms of their fixture im-
plications. Increasingly, hospital trustees,
managers, and medical stalimembers are going
to have to make rli~cult trade-off decisions
involving the volume and mix of services to
offer to different kinds of potential consumers.
These decisions will increasingly involve eth-
ical considerations. Hospitals wilIbe caned upon
to balance, in some way, health care as an
economic good with the conception of health
care as a social good. Physician and medical
staff input into this process is critical and,
therefore, the way in which hospitals solicit
this input becomes important. The new en-
vironment requires a more integrated man-
agement structure involving closer relationships
among trustees, hospital managers, and phy-
sicians in order to males decisions that balance
economic and social considerations to the ex-
tent possible.
The present findings are of interest because
they suggest that, to date, IO hospitals have
solicited physician input in different ways from
TABLE 11 Comparison of Hospitals in For-profit Systems with Other Hospital Types:
Does Hospital Have Committee for Cost Containment/Cost Awareness?
Hospitals in Hospitals in Hospitals in Hospitals in
For-profit Freestanding Religious Nonprofit Public Contract
Systems Hospitals Systems Systems Systems Managed
Response N % N % N% N % N% N %
l
Yes 13 10.32 238 16.20 4618.62 12 17.14 436.36 16 11.11
No 113 89.68 1,231 83.80 201 81.38* 58 82.86 7 63.64* 128 88.89
Total 126 100.00 1,469 100.00 247 100.00 70 100.00 11 100.00 144 100.00
*Chi-square significant at p s .10 when compared with hospitals in for-profit systems.
OCR for page 410
410
other kinds of hospitals, namely, greater in
volvement at the individual hospital board level
than at the managerial level of the organiza
tion. In contrast, other hospitals have essen
tially done the reverse. No studies exist to
suggest that one type of involvement is su
perior to another. It is likely that both types NOTES
will be increasingly needed in the fixture. To
the extent that this is true, one might expect
to find the better performing IO hospitals
moving to involve their physicians somewhat
more in the managerial activities of the hos
pital, and the better performing voluntary hos
pitals moving toward greater involvement of
their physicians in the governance and poli
cymaking activities of the organization. This
kind of"convergence" would be consistent with
those who suggest that IO and nonprofit sys
tems will become more similar in the fixture.
It is clearly an issue for fixture research with
the present findings serving as usefi~1 baseline
data.
A final issue relevant to both investor-owned
and voluntary systems is the level of the system
at which physician involvement occurs. The
findings discussed above have pertained to
physician involvement at the individual hos
pital level. There are data that suggest that
physicians are less involved at the divisional
and corporate levels of systems.4 22 To the ex
tent that systems, whether investor-owned or
voluntary, become larger and more central
ized, physician involvement at these higher
corporate levels would appear to be essential
to addressing the larger socioeconomic trade
offissues that will exist. Several systems, both
investor-owned and voluntary, are already
moving toward greater physician involvement
at higher levels, and fixture research should
continue to document this trend and examine
its impact on corporate decision malting.
ACKNOWLEDGMENT
This paper was Minded in part by contract
0551-4176 Tom the Institute of Medicine, Na
FOR-PROFIT ENTERPRISE IN HEALTH CARE
tional Academy of Sciences. The opinions and
conclusions expressed herein are solely those
of the authors.
~Brown, M. (1979) Multihospital systems: Implica-
tions for physicians. The Hospital Medical Staff (Au-
gust):2.
Reynolds, J., and A. E. Stunden (1978~1le orga-
nization of not-for-profit hospital systems. Health Care
Management Review 3:23.
3Starr, P. (~1982) The Social Transformation of Amer-
ican Medicine. New York: Basic Books.
gMorlock, L. L., J. A. Alexander, and H. Hunter
(1985) Governing board-CEO-medical staff rela-
tions in multi-institutional arrangements. Medical Care
23:1193-1213.
s The Hospital Med*al Staff (1978) AHA issues
guidelines on physician involvement in hospital gov-
ernance. 7:15.
6Nenhauser, D. (1971) The relationship between ad-
ministrative activities and hospital performance. Re-
search Series No. 28. Center for Health Administrative
Studies, University of Chicago.
7Shortell, S. M., S. W. Becker, and D. Nenhauser
(1976) The effects of management practices on hospital
efficiency and qualify ofcare. In Organization Research
in Hospitals, S. M. Shortell and M. Brown, eds. Chi-
cago: Blue Cross Association.
8Shortell, S. M., and J. P. LoGerfo (1981) Hospital
medical staE organization and quality of care: Results
for myocardial infarction and appendectomy. Medical
Care 19:1041.
9Morlock, L. L., C. A. Na~anson. S. D. Horn. and
D. N. Schumcher (1979) Organizational factors asso-
ciated with quality of care in 17 general acute care
hospitals. Paper presented at the annual meeting ofthe
Association of University Programs in Health Admin-
istration, Toronto.
2°Noie, N., S. Shortell, and M. Mornsey (1983) A
survey of hospital medical stabs-Part 1 (1983) Hos-
pitalsJAHA 57~1~.
Alexander, J., and D. Cobbs (1984) MDs and mul-
tihospital systems. The Hoszntal Medical Staff 13~6~:8-
14.
OCR for page 411
APPENDIX
TABLE A-1 Number of Physicians on the Governing Board
System Control Coefficients Relative to
Freestanding
Hospitals
Investor-Owned
Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital -1.55 .23***
System characteristics
System control
Religious nonprofit-.26 .14*- 1.81 .26***
Secular nonprofit-.06 .25- 1.49 .33***
Investor-owned1.55 .23***
Public4.23 .80***2.68 .83***
Contract-managed- . 29 .21-1.85 . 25* **
System size (100s).22 .08***.22 .08***
Hospital characteristics
Number of beds (100s).25 .04***.25 .04***
Regional location
Northeast.42 .15***.42 .15***
South- .27 .14*- .27 .14*
North Central-.49 .13***- .49 .13***
SMSA sizea
Under 100,000.40 .37.40 .37
100,000-250,000.46 . 17*.46 . 17*
250, 000-500, 000. 89 . 17** *.89 . 17* * *
500,000-1 million.81 .19***.81 .19***
1 million-2.5 million1.00 .15***1.00 .15***
Over 2.5 million1.47 .16***1.47 .16***
House sta8~100s)-.54 .11***- .54 .11***
Constant1.04 .12***2.59 .25***
Model Statistics
R2 .23 .23
N 2,025 2,025
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p ' .01.
**Chi-square significant at p s .05.
*Chi-square significant at p ' .10.
417
OCR for page 412
412
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TA;BLE A-2 Do Hospital Physician Governing Board Members
Have Voting Privileges?
System Control Coefficients Relative to-
Freestanding Investor-Owned
Hospitals Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital -1.12 .35***
System characteristics
System control
Religious nonprofit.44 .18**- .68 .38*
Secular nonprofit.30 .29- .82 .44*
Investor-owned1.12 .35***
Public-1.47 .75**- 2.59 .82***
Contract-managed- . 58 . 23* *-1. 70 . 38 * * *
System size (100s).46 .12***.46 .12***
Hospital characteristics
Number of beds (100s).30 .05***.30 .05***
Regional location
Northeast1.31 .19***1.31 .19***
South.18 .16.18 .16
North Central-.14 .15- .14 .15
SMSA sizes
Under 100,000.78 .51.78 .51
100, 000-250, 000. 40 . 20* *.40 . 20* *
25O, 000-500, 000.89 .22***.89 .22***
500,000-1 million.28 .23.28 .23
1 million-2.5 million.95 .19***.95 .19***
Over 2.5 million.39 .20**.39 .20**
House staE(100s)-.88 .14***-.88 .14***
Constant- . 25 .13*.88 . 36**
Model statistics
Pseudo R .35 ·35
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p c .01.
**Chi-square significant at p c .05.
*Chi-square significant at p c .10.
OCR for page 413
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE A-3 Are There Physicians on the Governing Board
Executive Committee?
System Control Coefficients Relative to-
.
Freestanding
Hospitals
_
Investor-Owed
Systems
Standard Standard
VariablesCoefficient ErrorCoefficient Error
Freestanding hospital - .17 .24
System characteristics
System control
Religious nonprofit-.57 .16***- .74 .28***
Secular nonprofit-.26 .27- .43 .35
Investor-owned.17 .24
Public- .49 .67- .66 .71
Contract-managed- . 03 .23- .20 .26
System size (100s).12 .09.12 .09
Hospital characteristics
Number of beds (100s).15 .04***.15 .04***
Regional location
Northeast.31 . 15**.31 .15**
South- .03 .15- .03 .15
North Central-.31 .15**- .31 .15**
SMSA sizea
Under 100,000.03 .40.03 .40
100,000-250,000.55 . 18***.55 . 18***
250,000 500,000.59 .17***.59 .17***
500,000-1 million.42 .19**.42 .19**
1 million-2.5 million.59 .16***.59 .16***
Over 2.5 million.55 .16***.55 .16***
House staEflOOs)-.29 .12**- .29 .12**
Constant- 1.13 .13***- .96 .26***
Model Statistics
Pseduo R.19 .19
N 2,067 2,067
a Size of standard metropolitan statistical area (SMSA).
***Chi-square significant at p c .01.
**Chi-square significant at p s .05.
413
OCR for page 414
414
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE A-4 Is the Hospital Chief Executive Officer a Voting
Member of the Governing Board?
System Control Coefficients Relative to
Freestanding
Hospitals
Variables
Standard
Coefficient Error
Investor-Owned
Systems
Standard
Coefficient Error
-2.67
Freestanding hospital
System characteristics
System control
Religious nonprofit
Secular nonprofit
Investor-owned
Public
Contract-managed
System size (100s)
Hospital characteristics
Number of beds (100s)
Regional location
Northeast
South
North Central
SSISA sizea
1.82
.32
2.67
-2.24
- .15
.05
.23
.36
-.16
.34
.16***
.29
.30***
1. 11**
.28 -
.11
.04***
.17***
.17
.65**
-
-.86
-2.35
-4.92
-2.82
.05
.23
.36
- .16
34
.
.30***
.32***
.39***
1.14***
.33***
.11
.04***
.17***
.17
.16**
Under 100,0001.06 .41***1.06 .41***
100,000-250,000.28 .20.28 .20
250,000-500,000.28 .20.28 .20
500,000- 1 million.45 .21 * *.45 .21 * *
1 million-2.5 million.51 .17***.51 .17***
Over 2.5 million.59 .18***.59 .18***
House staff (100s)- .38 .13***- .38 .13***
Constant-1.89 .15***.79 .31**
Model Statistics
Pseudo R .42 .42
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p ' .01.
**Chi-square significant at p ' .05.
OCR for page 415
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE A-5 Do Any Physicians Hold Salaried Positions as Part
of HospitaT's Administrative Team?
System Control Coefficients Relative to
Freestanding Investor-Owned
Hospitals Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital 1.40 .64*
System characteristics
System control
Religious nonprofit.39 .19**1.79 .65***
Secular nonprofit.88 .31***2.28 .69***
Investor-owned-1.40 . 64**
Public.27 .761.67 .98*
Contract-managed.11 .381.51 .67***
System size (loos)- .14 .18- .14 .18
Hospital characteristics
Number of beds (lOOs). 19 . 04* * *. 19 . 04* **
Regional location
Northeast.87 .21***.87 .21***
South- .32 .23- .32 .23
North Central-.06 .21- .06 .21
SMSA sizer
Under 10G,0001.19 .47**1.19 .47**
100,000 250,000.65 .27**.65 .27**
250,000-500,0001. 12 .24***1. 12 .24***
500,000 1 million1.12 .25***1.12 .25***
1 million-2.5 million.91 .23***.91 .23***
Over 2.5 million1.11 .23***1.11 .23***
House staE (loos).19 .13.19 .13
Constant-3.07 .21***- 4.47 .66***
Model Statistics
Pseudo R .38 .38
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p s .01.
**Chi-square significant at p s .os.
*Chi-square significant at p c .10.
475
OCR for page 416
416
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE A-6 Is the Hospital Chief of Staff Compensated?
System Control Coefficients Relative to
Freestanding Investor-Owned
Hospitals Systems
Variables
Standard Standard
CoefFicient Error Coefficient Error
_
Freestanding hospital .82 .79
System characteristics
System control
Religious nonprofit.17 .27.99 .81
Secular nonprofit1.11 .37***1.94 .84
Investor-owned-.82 .79
Public-.86 .97-.03 1.24
Contract-managed.29 .531.12 .87
System size (100s)-.51 .37- .51 .37
Hospital characteristics
Number of beds (100s).16 .05***.16 .05
Regional location
Northeast.50 . 28*.50 . 28
South- .10 .31- .10 .31
North Central-.20 .30- .20 .30
SMSA sizea
Under 100,000- 6.15 24.96-6.15 24.96
100, 000-250, 000. 32 . 54.32 .54
250,000-500,0001.34 .40***1.34 .40
500,000-1 million1.99 .37***1.99 .37
1 million-2.5 million1.91 .34***1.91 .34
Over 2.5 million1.67 .36***1.67 .36
House staff (100s).23 .14*.23 .14
Constant-4.32 .35***- 5.14 .84
Model Statistics
Pseudo R .39 .39
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p 5 .01.
**Chi-square significant at p ' .05.
*Chi-square significant at p ' .10.
OCR for page 417
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE A-7 Is the Director of Medical Education
Compensated?
System Control Coefficients Relative to
Freestanding Investor-Owned
Hospitals Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital .71 .45
System characteristics
System control
Religious nonprofit .06 .19 .78 .46*
Secular nonprofit -.18 .37 .54 .55
Investor-owned - .71 .45
Public - .44 .80 .28 .91
Contract-managed - .50 .45 .21 .54
System size (100s) -.17 .20 -.17 .20
Hospital characteristics
Number of beds (100s) .51 .05*** .51 .05***
Regional location
Northeast .03 .20 .03 .20
South - 1.01 .23*** - 1.01 .23***
North Central - .14 .20 - .14 .20
SMSA sizea
Under 100,000 1.48 .53*** 1.48 .53***
100,000-250,000 1.48 .28*** 1.48 .28***
250,000-500,000 1.73 .27*** 1.73 .27***
500,000-1 million 2.02 .28*** 2.02 .28***
1 million-2.5 million 1.91 .25*** 1.91 .25***
Over 2.5 million 2.13 .26*** 2.13 .26***
House staff (100s) - .52 .14*** - .52 .14***
Constant -3.68 .24*** - 4.39 .48***
Model Statistics
Pseudo R .51 .51
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p s .01.
*Chi-square significant at p ' .10.
417
OCR for page 418
418
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE A-S Number of Medical Staff Committees
System Control Coefficients Relative to
Freestanding Investor-Owned
Hospitals Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital 2.27
System characteristics
System control
Religious nonprofit .55 .49 2.82
Secular nonprofit -1.02 .86 1.25
Investor-owned -2.27 .80***
Public - 8.17 2.74*** - 5.92
Contract-managed -1.06 .71 1.21
System size (100s) .11 .28 .11
Hospital characteristics
Number of beds (100s) 2.82 .12*** 2.82
Regional location
Northeast 1.02 .50** 1.02
South -2.61 .47*** -2.61
North Central -2. 99 .45*** - 2.99
SMSA sizea
Under 100,000 .88 1.25 .88
100,000-250,000 3.79 .ss*** 3.79
2s0,000-s00, 000 1.55 .67*** 1.55
500,000-1 million 3.12 .64*** 3.12
1 million-2.5 million 4.23 .51*** 4.23
Over 2.5 million 5.10 .54*** 5.10
House staff (100s) -3.44 .39*** - 3.44
Constant 8.02 .42*** 5.75
Model statistics
R2 .45 45
N 2,025 2,025
CSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p ~ .01.
**Chi-square significant at p ' .05.
.80***
.88***
1.12
2.84**
.86
.28
. 12***
.50**
.47***
.4s***
OCR for page 419
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE A-9 Does the Hospital Have a Committee for Cost
Containment or Cost Awareness?
System Control Coefficients Relative to
Freestanding
Hospitals
Investor-Owned
Systems
Standard Standard
Variables Coefficient Error Coefficient Error
Freestanding hospital .19 .36
System characteristics
System control
Religious nonprofit.14 .19.37 .39
Secular nonprofit.05 .34.24 .47
Investor-owned-.19 .36
Public.14 .72.33 .80
C o n t r a c t - m a n a g e d- . 0 5 . 3 2. 1 4 . 4 1
System size (100s)-.16 .14- .16 .14
Hospital characteristics
Number of beds (100s).19 .04***.19 .04
Regional location
Northeast.29 .19.29 .19
South- .02 .19- .02 .19
North Central-.44 .19**- .44 .19
SMSA sizea
Under 100,000-.34 .51- .34 .51
100,000-250,000- . 12 .24- . 12 .24
250, 000-500, 000- .43 . 25*- .43 . 25
500,000-1 million-.16 .25- .16 .25
1 million-2.5 million-.10 .20- .10 .20
Over 2.5 million-.16 .21- .16 .21
House sta~4100s).03 .13.03 .13
Constant-1.89 .17***- 2.07 .38
Model statistics
Pseudo R .14 .14
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p ' .01.
**Chi-square significant at p c 05.
*Chi-sqmre significant at p ' .10.
479
OCR for page 420
420
FOR-PROFIT ENTERPRISE IN HEALTH CARE
TABLE A-10 Does the Hospital Have a Committee for
Medical Staff Long-Range Planning?
System Control Coefficients Relative to
Freestanding Investor-Owned
Hospitals Systems
Variables
.
Standard Standard
Coefficient Error Coefficient Error
Freestanding hospital .93 .32
System characteristics
System control
Religious nonprofit-.04 .16.90 .34
Secular nonprofit.03 .28.96 .40
Investor-owned- .93 .32***
Public- .65 .73.29 .79
Contract-managed- .52 . 27*.42 .34
System size (100s).08 .11.08 .11
Hospital characteristics
Number of beds (100s).20 .04***.20 .04
Regional location
Northeast.28 .16*.28 .16
South.01 .16.01 .16
North Central-.06 .15- .06 .15
SMSA sizea
Under 100,000.15 .40.15 .40
100, 000-250, 000. 14 . 19. 14 . 19
250,000-500,000- . 16 . 19- . 16 . 19
500,000-1 million.02 .21.02 .21
1 million-2.5 million.10 .17.10 .17
Over 2.5 million.22 .17.22 .17
House staff (100s)-.34 .13***- .34 .13
Constant- 1.33 .14***-2.26 .33
Model statistics
Pseudo R .14 .14
N 2,067 2,067
aSize of standard metropolitan statistical area (SMSA).
***Chi-square significant at p c .01.
**Chi-square significant at p s .05.
*Chi-square significant at p c .10.
OCR for page 421
PHYSICIAN PARTICIPATION IN GOVERNANCE
TABLE A-ll Descriptive Statistics for Hospital Sample Subset
(N = 2,025)
Variables
Standard Number
Mean Deviation in Samplea
Independent Variables
Freestanding hospital.71.451,442
System characteristics
System control
Religious nonprofit.12.32241
Secular nonprofit.03.1868
Investor-owned.06.24125
Public.003.067
Conkact-managed.07.26142
System size (100s)21.3172.97
Hospital characteristics
Number of beds (100s)190.53178.50
Regional location
Northeast.23.42460
South.26.44533
North Central.32.41647
West.19.39385
SMSA sizes
Non-SMSA.45.50906
Under 100,000.02.1232
100,000 250,000.09.28178
250,000 500,000.09.29184
500,000-1 million.08.27155
1 million-2.5 million.14.35293
Over 2.5 million.14.34277
House staff (100s)11.4950.04
Dependent Variables
Number of M.D.s on governing board 1.96 2.27
Number of medical staff committees 13.44 9.13
aFor dichotomously scored variables.
bSize of standard metropolitan statistical area (SMSA).
421
Representative terms from entire chapter:
mean mean mean
