Rejoinder to taxonomy of health networks and systems: a reassessment

In his commentary upon the taxonomy of health a whole s and networks that we originally evolveed in Bazzoli et al. (1999) and updated end Dubbs et al. (2004), Luke raises various affects about the underlying concepts, measures, and approaches we used to exhibit our classification scheme. His primary be of importance tos are: (1) a bias in a whole assignment occurs because the taxonomy categories capture multimarket configurations of combination of parts to form a wholes rather than centralization per se; (2) hospital service configuration data do not provide relevant information about the locus of health system/network decision making; (3) the conceptual framework used may not be relevant for health networks; and (4) measurement error exists in certain variables. We address each of these issues in this rejoinder.

Before commenting upon these points, we note that our primary drift for developing the taxonomy in the late 1990 was to examine the mode of building and strategy of health networks and combination of parts to form a wholes as the American Hospital Association (AHA) and others defined them. The AHA had a lengthy history of tracking these organizations, collecting information upon multihospital systems starting in the mid-1970s and upon health networks beginning in 1993 above time, the objectives and constitution of these organizations changed in replication to changing market imperatives. greatest in quantity notable was the movement in the mid-1990s to unravel organized delivery systems in anticipation of the Clinton administration's Health Security Act of 1994 and in reply to the growing belief that capitated contracting between providers and health plans would become public There was widespread acknowledgement among researchers and the industry that the organizations tracked through the AHA were growing more heterogeneous, and this l to pertain to that health services research that attempted to measure a a whole or network effect on hospital behavior would provide misleading information given the diversity of these organizations.

This sparked our interest, and that of the Agency for Healthcare Research and Quality, which capitaled our research, in developing tools for researchers, the hospital industry, and policy makers for a like reason they could identify and examine more finely grained, homogenous collections of health networks and systems

CONCEPTUAL FRAMEWORK, manners AND FINDINGS

The conceptual framework for the two our original taxonomy research and the updated analysis drew heavily upon industrial organization economics and organization theory to identify three lock opener characteristics that distinguished hospital organizations: differentiation and integration (Lawrence and Lorsch 1967); and centralization (McKelvey 1975; Miller and Friesen 1984) In our particular words immediately preceding [i]or[/i] following hospitals developing organized delivery combination of parts to form a wholes in the 1990s were making critical decisions that affected all three of these dimensions. They were deciding about: (1) the emblem and scope of services to tender so that a broad continuum of primary, preventive, acute, and chronic health services would be near (i.e., differentiation); (2) the amplitude to which specific services were delivered by the agency of one or a few network/system affiliates versus being dispersed over the system (i.e., the stage of centralization); and (3) the use of network/system affiliates to deliver specific health services versus arranging service delivery from one side outside vendors (i.e., mechanisms to integrate activity). Our empirical measures for these conceptions focused on the three building block ups of organized delivery systems, namely the array of hospital services provided, physician organizations lay opened to facilitate health plan contracting (eg physician hospital organizations and management service organizations), and provider-sponsored insurance harvests (Shortell et al. 1993; Dowling 1995; Robinson and Casalino 1996)

Using cluster analysis and other related empirical approaches typically applied in taxonomic research (Lewis and Alexander 1986; Weiner and Alexander 1993; Alexander et al. 1996; Ketchen and Shook 1996) we identified a four category scheme for classifying health networks and a five category scheme for health combination of parts to form a wholes We used a variety of statistical meanss to assess the reliability, stability, and validity of these classifications. Table 1 provides descriptions of the 1994 a whole and network clusters drawn from our original article. Our updated analysis of 1998 revealed similarities on the contrary also some important differences in the a whole and network clusters. In particular, we ground growing prevalence and diversity among decentralized organizational forms.

MAJOR POINTS RAISED IN COMMENTARY

Luke makes four main make comments [i]or[/i] remarkss on our taxonomy that we address in turn

Bias in Taxonomy Because of Multimarket versus Single-Market Systems

The central issue raised by the agency of Luke relates to the distinction between a whole s with hospitals in multiple markets, which he calls hospital companies, and local clusters of combination of parts to form a whole hospitals. He defines local clusters in a manner consistent with Cuellar and Gertler (2003) namely cases in which sum of two units or more hospitals from the same combination of parts to form a whole are present in a given market. Luke acknowledges that these general [i]or[/i] abstract notions are not mutually exclusive, namely that a certain quantity of health systems will have local clusters of hospitals in more than individual market. (1) In fact, a careful examination of the 2000 data reported in Cuellar and Gertler (2003) indicates that greatest in quantity system hospitals (75 percent) belong to local clusters in that they are in a market where at least single other system partner is at hand (2) Thus, many health a whole s even if they have geographically dispersed hospital holdings, have ample opportunities to implement the sharing of services and physician/insurance arrangements among affiliated hospitals located in the same market.