Abstract
Purpose. Integration within healthcare delivery systems is an increasingly common trend in the United States health industry. The majority of studies to date have focused on the system from a hospital's perspective. This study took the view of California health maintenance organizations when examining the HMO's degree of integration with hospitals and physicians. Specifically, the intent was to determine if there is a relationship between HMO integration and certain HMO performance measures. These measures were defined as profitability, efficiency, quality of care, patient satisfaction, enrollment size, and market characteristics. Theoretical framework. This dissertation was grounded in systems and network theory. The essence of integration in health care is multidimensional. Most complex networks are multidimensional. Integration is a function of a variety of variables including physician leadership, governance structure, risk and incentives, commonality of management, commonality of ownership, subsystem integration, geographic access, supply of health services, and information systems. Methodology. The degree of HMO integration was assessed from a survey instrument adapted from the literature. HMO performance measures were extricated from three different sources of secondary data. The sources were the California Department of Corporations, the California Association of Health Plans, and the National Committee on Quality Assurance. A variety of variables made up each performance measure. For this multivariate study, the researcher used analysis of variance (ANOVA), F-test, t-test of difference for independent samples, and stepwise multiple regression. Findings. The degree of integration of California HMOs was lower than expected. The mean integration score was in the medium-low to medium integration interval. The greatest contributor to total integration was the level of systemness. The level of systemness contributed over 50 percent of the variability in the total integration scores. Overall, integration had little relationship to HMO performance measures. When a relationship was extant, it was usually a very weak negative correlation, meaning that higher levels of integration were associated with poor performance. Two notable exceptions were enrollment size and asset management. Higher integration was associated with larger enrollment sizes and better asset management ratios. Further, not-for-profit HMOs exhibited a significantly higher degree of integration than for-profit HMOs. Conclusions and recommendations. According to this study, there is generally no relationship between California HMO integration and California HMO performance measures (exceptions noted). Integration efforts may not have lived up to their expectations. Integration, however, is still in its infancy and may not have had a chance to fully mature. The jury is still out on the efficacy of integration.