here appears to be limited attention paid to the use of tools and techniques to influence physician practice patterns and delivery of care. Respondents report that the primary emphasis of deal making is on price, with limited attention to other factors. In addition, because plans contract with many providers, no single plan is important enough to a provider’s practice, thereby decreasing the potential to influence the management of care.

Health systems and health plans are in various stages of developing and implementing clinical tools. Numerous utilization review and case management efforts have been put in place by hospitals using protocols and guidelines. Both health plans and hospitals are testing physician profile and disease management tools and report different levels of development of information systems to support these efforts. For example, AV-Med is testing a physician profiling system that has been used to look at primary care physicians’ referral patterns to specialists. Information was generated and shared with the physicians but has not been linked to any incentives. Disease management efforts are being used by Jackson Memorial for tuberculosis and diabetes, and AV-Med has a diabetes management program that works with the primary care physicians in its network.

Some changes in the delivery of care are evolving, mostly shifts from inpatient to ambulatory care, including development of more off-campus clinics by hospitals. Many hospitals report increased use of ambulatory care sites as a strategy to retain and/or capture patients. For example, Mount Sinai, in concert with several partners, is developing ambulatory care sites to attract more patients and to move some services away from the hospital. Columbia/ HCA is actively buying more ambulatory care surgical facilities. Miami Children’s Hospital owns and manages ambulatory pediatric practices. In addition, some of the community health centers and hospitals operate school-based health centers.

Health plans are beginning to redirect some of their volume, specifically low-risk deliveries, to lower-cost and non-tertiary facilities with the capacity to handle normal deliveries and only sending high-risk patients to Jackson Memorial. As a result, the number of Jackson deliveries has decreased from 17,000 to 7,000 in the past year. Jackson Memorial’s response has been to try to gain back some of the deliveries by expanding hospital privileges to physicians at the community health centers and to other community physicians to increase Medicaid deliveries. The health centers view this as a major improvement in their ability to provide continuity of care for their patients.