linical decision making still appears to be in the hands of individual physicians in Syracuse, unlike other communities, where large medical groups, hospitals or insurers and purchasers exert greater influence. Providers do not appear to have explicit incentives (i.e., capitation or performance-based contracting) or information-based tools (guidelines, profiling) to initiate major changes in clinical practice patterns or the delivery and organization of care.

Retention of physician control over clinical practice stems from several factors, including limited HMO penetration and the "loose" nature of managed care in the Syracuse area. The overlapping structure of physician and hospital networks and the absence of formal referral arrangements make it difficult for a single entity to impose standardized clinical practices. There are few strong financial incentives to direct clinical practice, because most arrangements are based on fee-for-service or discounted payment schedules.

PHP’s contracts with the Crouse-Irving Memorial PHO and PHP’s own Health Service Medical Group are important exceptions. They feature global capitation for professional services and inpatient risk pools. Under the risk pool arrangement, any surplus or deficit in pooled funds is shared among physicians. Risk-sharing is limited to 20 percent of the pool’s value. It is not clear, however, whether this arrangement is affecting clinical practice patterns. Providers tend to describe the utilization review mechanisms imposed by health plans more as administrative "hassles" than as factors in clinical practice.

The SUNY Health Sciences Center appears to exert an important, broad-level influence on clinical practice in the Syracuse area. Respondents said they believe the Health Sciences Center’s role in training and employing physicians has contributed to the preponderance of specialists and the reputed high level of physician skill.

Many respondents said clinical practice guidelines are attracting more attention, particularly among health plans. PHP uses guidelines developed by Milliman & Robertson, among others, and it relies on a network medical director and physicians nominated by participating PHOs to promote acceptance and use of the guidelines.

Provider organizations also described guideline development activities. The Syracuse Community Health Center, the HEC, individual hospitals and PHOs all reported that they were developing protocols and guidelines. However described, the hospitals led some efforts more along the lines of standard quality assurance reviews than aggressive efforts to change care practices. The New York State Cardiac Monitoring Study, which reports hospital mortality rates for open-heart surgery, appears to have spurred the development of guidelines around invasive cardiology procedures.

In contrast to the development of guidelines to influence clinical processes, activity around outcomes evaluation appears to be much more tentative. Health plans report use of profiling systems for utilization management and to credential network providers. Hospitals and PHOs are interested in developing information systems that can link inpatient and outpatient clinical records with administrative data. Respondents said many of these initiatives are directed principally at administering and managing physician activities, while others are designed to improve clinical practice. Crouse-Irving Memorial recently formed a subsidiary to develop a data system to manage clinical and administrative data, and University Hospital has created a clinical outcomes analysis unit.

In a different vein, changing clinician roles may have an impact on care delivery. In particular, primary care practitioners appear to be gaining influence in several respects. Primary care physicians are becoming increasingly attractive to hospitals and health plans, as evidenced by a skirmish between St. Joseph’s and Crouse-Irving Memorial Hospital over family practice programs. St. Joseph’s has housed SUNY’s family practice residency and has long been aligned with family practice groups. A few years ago, Crouse-Irving Memorial purchased several family practices that had been aligned with St. Joseph’s, in what many respondents refer to as "the opening shot" in direct competition between Syracuse hospitals. In the outlying areas of Madison, Oswego, Oneida and Auburn, providers acknowledged heavier reliance on mid-level practitioners.

Changes in referral patterns and patient use are unclear. A variety of less formal attempts are underway to direct referrals. Hospitals at least implicitly expect referrals from owned physician groups or from groups tied into management service contracts with hospitals, and there are in fact a few strong referral relationships between multispecialty group practices and particular health plans and hospitals.

Overall, integration of clinical care among provider organizations appears to be very limited.