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Performance metrics have become widely used and much lamented – about tools for measuring healthcare quality. In this paper, the authors reflect on the development and use of performance metrics in healthcare regulation and clinical practice. Studying multi-actor settings of performance measurement systems in healthcare in Sweden and the Netherlands, the authors show how regulatory agencies (i.e., the inspectorate and national registries), patients, hospitals, and practitioners engage in the constitution of healthcare practices through developing performance indicators that form the input for ranking, ensuing intensive dialogues on what should be measured and accounted for, and to what effects. The authors analyze this process as caring for numbers. The authors discern two practices of caring for numbers: validating and contexting. Validating refers to the practices of making numbers reflect those practices they intend to depict; contexting is about how with the use of numbers specific contexts of healthcare are built. These processes together emphasize the performative character of numbers as well as the reflexive uses of performativity. The paper shows how collaborative and rather pragmatic practices of caring for numbers co-construct specific practices of healthcare. Though this reflexive entanglement of production and use of numbers actors not only constitute specific performance metrics and ranking practices but also perform healthcare.

The relationships of physician practice characteristics, care management effectiveness, autonomy, and managed care involvement, and physicians’ practice and career satisfaction were investigated. A panel sample (N=660) of 6800 physicians was made up of eleven physicians randomly selected from each of the sixty communities. Three latent constructs include care management effectiveness, practice autonomy, and openness in private practice. Multilevel modeling was performed. A statistically insignificant association was found between the perceived effectiveness of care management and physician satisfaction, holding the practice characteristics and other perception factors constant. The study demonstrated direct effects of practice characteristics and care management effectiveness on the practice of gate-keeping functions and on earnings. Only two contextual variables, managed care penetration and median income in the study communities, were related to physicians’ practice.

In this chapter organizational theory is used to clarify and synthesize the large and diverse literature on the relationship between managed care (MC) and ethnic differences in access to health services. MC practices are classified by whether they are used by health care organizations to define their boundaries or to coordinate care. MC practices used to coordinate care are further categorized as one of five types: rules and programs, authority, goal setting, culture, or client coordination. This review also presents hypotheses derived from this literature that specify the predicted effects of MC practices on ethnic differences in access to health services. It was found that few of these hypotheses had been empirically investigated and although some evidence was found that MC boundary-setting practices disadvantage minorities, there were not consistent findings with respect to those practices used to coordinate care.

Purpose: While COVID-19 has upended lives, it has also catalyzed innovation with potential to advance health delivery. Yet, we know little about how the delivery system, and primary care in particular, has responded and how this has impacted vulnerable patients. We aimed to understand the impact of COVID-19 on primary care practice sites and their vulnerable patients and to identify explanations for variation. Approach: We developed and administered a survey to practice managers and physician leaders from 173 primary care practice sites, October-November 2020. We report and graphically depict results from univariate analysis and examine potential explanations for variation in practices' process innovations in response to COVID-19 by assessing bivariate relationships between seven dependent variables and four independent variables. Findings: Among 96 (55.5%) respondents, primary care practice sites on average took more safety (8.5 of 12) than financial (2.5 of 17) precautions in response to COVID-19. Practice sites varied in their efforts to protect patients with vulnerabilities, providing care initially postponed, and experience with virtual visits. Financial risk, practice size, practitioner age, and emergency preparedness explained variation in primary care practices' process innovations. Many practice sites plan to sustain virtual visits, dependent mostly on patient and provider preference and continued reimbursement. Value: While findings indicate rapid and substantial innovation, conditions must enable primary care practice sites to build on and sustain innovations, to support care for vulnerable populations, including those with multiple chronic conditions and socio-economic barriers to health, and to prepare primary care for future emergencies.

This paper examines the relationship between human resource practices in 173 hospitals in the United Kingdom and four organizational outcome categories – clinical, financial, employee attitudes and perceptions, and patient attitudes and perceptions. The overarching proposition set forth and examined in this paper is that human resource management (HRM) practices and delivery of care practices have varied effects on each of these outcomes. More specifically, the authors set forth the proposition that specific practices will have positive effects on one outcome category while simultaneously having a negative effect on other performance outcomes, broadly defined.

The paper introduces a broader stakeholder framework for assessing the HR–performance relationship in the healthcare setting. This multi-dimensional framework incorporates the effects of human resource practices on customers (patients), management, and frontline staff and can also be applied to other sectors such as manufacturing. This approach acknowledges the potential for incompatibilities between stakeholder performance objectives. In the healthcare industry specifically, our framework broadens the notion of performance.

Overall, our results provide support for the proposition that different stakeholders will be affected differently by the use of managerial practices. We believe that the findings reported in this paper highlight the importance of examining multiple stakeholder outcomes associated with managerial practices and the need to identify the inherent trade-offs associated with their adoption.

This paper explores and elaborates on emotions and capability in organizations through the phenomenon of care. Drawing upon multi-disciplinary theory, as well as empirical material from a case study in the hotel industry (involving four organizations), a theoretical framework is offered for understanding the multidimensional, dynamic, social relational nature and role of care in organizations. This is shown through the suggestion of a conceptual framework of four ideal types of practices in frontline work. In the practice of care, emotions are one of the vital parts in a larger whole. Regarding the role of care in organizations, it is suggested that what, and how, one cares for, are continually created, tested, negotiated and/or re-constructed. This paper suggests that the claims regarding care also provide implications for the study and understanding of emotions and capability in organizations.

Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway.

We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models.

The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners.

While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization.

Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices.

Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats.

This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.

There are longstanding concerns about the sustainability of the US health care system. Payment reform has been seen over the last decade as a key strategy to reorienting the US health care system around value. Alternative payment models (APMs) that seek to accomplish this goal have become increasingly prevalent in the US, yet there is a perception that physicians are resistant to their use and that organizations have been slow to adopt such models. The reasons for the limited effectiveness of APM programs are multifactorial and include aspects related to the design and implementation of these programs and lack of alignment and coordination across different payers and health care sectors. Most importantly, however, is that the current organizational structures in US health care serve to dampen the direct impact of these incentives, often because health care delivery organizations face conflicting incentives themselves. Organizations filter and refine the incentives from multiple external payment contracts and develop internal incentive systems that best reflect the amalgamation of the incentives embedded across their contracts, and thus the fragmented nature of the US health care system serves to undermine efforts to transform care under value-based contracts. In addition to organizations having conflicting incentives, there also are fundamental problems with the design and implementation of APMs that hinder their acceptance among physicians and the organizations in which they work. Moreover, much remains to be learned about how organizations can best adapt to succeed under these models, and how organizational culture can be leveraged to transform care.

Despite continuing debate about costs and benefits, managed care became an integral part of the health care sector during the 1990s. In this paper, we examine the organizational and practice variation in the managed care industry at two points in the 1990s using a national census of organizations operating in those years. We use a definition of managed care that captures the increased diversity within the industry while still distinguishing it from traditional indemnity, fee-for-service care. We draw on institutional theory to begin to formulate a framework for understanding why certain organizational forms and practices emerged when and where they did.

The tradition of medicine has until now been characterized by an aspiration to provide as complete as possible a service of care to the populations to which it owes responsibility. The same holds for nursing and caring practices, but the tradition is loosening. Despite the collective assumption that medical and nursing practice rests on solid grounds of knowledge and is framed by a caring ethos, change in practice not only has typically come about in a complex and diffuse fashion, but has also come along with sacrifices, losses and deficits.