title: A Review and Survey of Neurosurgeon-Hospital Relationships: Evolution and Options.
abstract: As healthcare delivery shifts from fee-for-service, episodic care to pay for performance and population health, both hospitals and physicians are looking for new forms of integration. A number of regulations and restrictions govern physician relationships with hospitals. In this paper, we review the legal basis for such relationships and the options available. We also survey neurosurgeons and hospital executives to gain their perspective on the current situation and likely future. Two series of structured interviews were conducted with 10 neurosurgeons who work in a range of situations in diverse markets, and with Memorial Hermann Healthcare System senior executive leadership. Their responses form the basis for the subsequent discussion. Neurosurgeons can be independent, join a confederation such as an Independent Physician Association or another type of "clinically integrated" network, or be employed by a hospital, medical school, or physician group. With varying levels of integration comes the strength of size, management expertise, negotiating leverage, economies of scale, and possibly financial advantages, but with impact on autonomy and independence. Constructive alignment can lead to a win-win situation for both the individual physician and the organization, but options vary widely due to heterogeneous local conditions. This paper reviews possible relationships, moving along a spectrum from no financial integration to full integration. Concepts such as physician leasing, professional service agreements, "clinical integration," and employment are presented. This paper offers a practical reference that might be useful to a new graduate, independent neurosurgeon considering integration, or employed physicians considering alternatives.
authors.affiliation: Department of Neurosurgery, The Uni-versity of Texas Medical School at Hous-ton, Houston, Texas.
authors.forename: Dong H
authors.initials: DH
authors.lastname: Kim
authors.affiliation: Norton Rose Ful-bright, Houston, Texas.
authors.forename: Bernard
authors.initials: B
authors.lastname: Duco
authors.affiliation: Memorial Her-mann Healthcare System, Houston, Texas.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wolterman
authors.affiliation: Memorial Her-mann Healthcare System, Houston, Texas.
authors.forename: Charles
authors.initials: C
authors.lastname: Stokes
authors.affiliation: Memorial Her-mann Healthcare System, Houston, Texas.
authors.forename: Rod
authors.initials: R
authors.lastname: Brace
authors.affiliation: ¶Department of Neurosurgery, Columbia University, New York, New York.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Solomon
authors.affiliation: Depart-ment of Neurosurgery, Indiana Uni-versity, Indianapolis, Indiana.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Barbaro
authors.affiliation: Houston Spine and Neurosurgery Center, Hous-ton, Texas.
authors.forename: Richard
authors.initials: R
authors.lastname: Westmark
authors.affiliation: Neurosurgical Association of Houston, Houston, Texas.
authors.forename: David
authors.initials: D
authors.lastname: MacDougall
authors.affiliation: Department of Neurosurgery, Baptist Health Hospi-tal, Lexington, Kentucky.
authors.forename: James
authors.initials: J
authors.lastname: Bean
authors.affiliation: Department of Neurosurgery, The Uni-versity of Texas Medical School at Hous-ton, Houston, Texas.
authors.forename: Joanna
authors.initials: J
authors.lastname: O'Leary
authors.affiliation: Department of Neurosurgery, Kaiser Permanente, Red-wood City, California.
authors.forename: Nicole
authors.initials: N
authors.lastname: Moayeri
authors.affiliation: Department of Neurosurgery, Washington University, St. Louis, Missouri.
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Dacey
authors.affiliation: Department of Neu-rological Surgery, University of California, San Francisco, San Francisco, California.
authors.forename: Mitchel S
authors.initials: MS
authors.lastname: Berger
authors.affiliation: Department of Neurosurgery, Pennsyl-vania State University, Hershey, Pennsyl-vania.
authors.forename: Robert
authors.initials: R
authors.lastname: Harbaugh
mesh_terms: D001291:Attitude of Health Personnel; D003695:Delivery of Health Care / Q000458:organization & administration*; D018578:Hospital-Physician Relations; D006801:Humans; D000069471:Neurosurgeons; D011795:Surveys and Questionnaires; D014481:United States
keywords: Contracts; Economics; Hospitals; IPA; Physicians; Private; Relationship