espite significant changes in health care organization, there does not yet appear to be a high degree of administrative or clinical integration within these newly concentrated entities. Nor has there been any significant reduction in capacity.

Ownership models of consolidation generally convey a greater level of administrative integration. The University Hospitals Health System, for example, employs many of its physicians, manages budgeting centrally and is making significant investments in unified information systems. UHHS also plans to centralize billing, human resources and management information systems. The Fairview and Columbia/HCA-Sisters of Charity systems also centralize such administrative and financial functions. But a great deal of administrative integration still appears to be in the planning stages. In nonownership affiliations, such as the Cleveland Health Network, the organization is intentionally decentralized, retaining considerable administrative autonomy for the member organizations. For example, CHN members manage their own billing functions, but pass data on to the network for physician profiling and clinical guidelines development.

Clinical integration is also limited. Most systems describe plans for unified clinical data systems, clinical pathways development and consolidated clinical management of departments and ancillary functions. UHHS has consolidated radiology services and plans to integrate urology, cardiovascular and cancer services across its hospitals. The Fairview system has unified the heads of its departments and consolidated radiology and anesthesia services. Within CHN, MetroHealth staffs the emergency departments for the Cleveland Clinic and the Meridia System, and has an affiliation with the Cleveland Clinic to support its neonatology program. The Cleveland Clinic directs radiation oncology at Fairview and Meridia Hillcrest.

Additional consolidation and integration of clinical care was still being planned. For example, PHS was reportedly beginning to establish single-specialty departments across its four member hospitals, and the Meridia system was planning to reorganize clinical services into centralized product lines across its hospitals.

Respondents believe that physicians still control the course of day-to-day clinical practice in the Cleveland area. However, consumer expectations regarding health care services are rising as more information becomes available to them. Numerous anecdotes tell of patients who approach their providers with the results of their own Internet literature searches and print journal articles. More significant is the broadly shared view that information and involvement from parties outside the doctor-patient relationship are beginning to wield significant influence on individual clinical decisions.

Several factors are contributing to this increased involvement of third parties, including the migration of solo practitioners into group practices, where consistent clinical practice across physicians is expected. One is the increasing availability of practice guidelines, such as those disseminated by the federal Agency for Health Care Policy and Research. Several large group practices have adopted data-driven internal quality review processes and consensus standards for best practices, and local health plans and hospital systems reported increased reliance on practice guidelines. When pressed, however, most agreed that implementation of these guidelines is not yet fully operational.

Some health plans and large providers are trying to influence physician practice patterns through profiling activi- ties that rely on data collection and feedback. In this manner, physicians can see how their practices compare with those of their peers. That objective is not always met, however. Physicians complained about receiving feedback data from multiple sources in different formats, which makes comparisons difficult. A few providers and most plans say they are making profiling a cornerstone of their approach to care management, and intend to make that information more accessible, consistent and credible. They emphasize that they are not interested in policing clinical practice, but in working collaboratively with clinicians to jointly identify best practices.

In general, physicians have not been subjected to tight utilization controls, strict practice guidelines or strong financial incentives to influence their clinical decisions. Despite considerable discussion about practice guidelines, there is little evidence of their use or impact on care. Utilization review activities are generally quite basic, typically focused on length of stay. The state is designing a new system of measuring quality and performance, but its precise shape and impact on physician practice is unclear. Health plans and provider systems talk about the importance of working with physicians as partners and staying out of their way. Scattered financial incentives are in use, but the lack of capitated arrangements and the large numbers of full-time salaried physicians limit their impact. One plan offers physicians a bonus based on individual performance in addition to their per-member-per-month capitation payments. Several groups and networks are offering equity ownership as a way of aligning physicians’ interests with larger organizational objectives.

Although many of the recent organizational changes have been expressly designed to shift or at least solidify referrals, there is little hard evidence that referral patterns have changed significantly as a result. Identified referral shifts typically involve the realignment of physicians from one hospital to another, or the opening of a new service. Some new ambulatory care sites are emerging, typically in Cleveland at urban churches and malls, and are geared to the Medicaid population. Some evidence was cited that generalist physicians are providing their patients with care that previously might have been referred to a specialist. At the same time, specialists reportedly are providing more primary care or moving fully into generalist practice as their incomes drop. One large physician group described how it assigned generalist medicine patients to specialists to fill their time and improve productivity. Primary and specialist physicians say they will adopt a disease management approach to provide the full spectrum of care across an episode of illness or the course of a chronic disease.

Respondents cite an increase in health education and prevention activities, some of these by HMOs and Medicaid managed care organizations and some by employers. The rapid turnover of health plans by employers has limited this activity, and two county health departments cited the growing volume of patients seeking immunizations at public health clinics as evidence of a decline in preventive services provided in the private sector.