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A systematic review of vertical integration and quality of care, efficiency, and patient-centered outcomes

Machta, Rachel M.; Maurer, Kristin A.; Jones, David J.; Furukawa, Michael F.; Rich, Eugene C.

doi: 10.1097/HMR.0000000000000197
Features: PDF Only

Background: Small independent practices are increasingly giving way to more complex affiliations between provider organizations and hospital systems. There are several ways in which vertically integrated health systems could improve quality and lower the costs of care. But there are also concerns that integrated systems may increase the price and costs of care without commensurate improvements in quality and outcomes.

Purpose: Despite a growing body of research on vertically integrated health systems, no systematic review that we know of compares vertically integrated health systems (defined as shared ownership or joint management of hospitals and physician practices) to nonintegrated hospitals or physician practices.

Methods: We conducted a systematic search of the literature published from January 1996 to November 2016. We considered articles for review if they compared the performance of a vertically integrated health system and examined an outcome related to quality of care, efficiency, or patient-centered outcomes.

Results: Database searches generated 7,559 articles, with 29 articles included in this review. Vertical integration was associated with better quality, often measured as optimal care for specific conditions, but showed either no differences or lower efficiency as measured by utilization, spending, and prices. Few studies evaluated a patient-centered outcome; among those, most examined mortality and did not identify any effects. Across domains, most studies were observational and did not address the issue of selection bias.

Practice Implications: Recent evidence suggests the trend toward vertical integration will likely continue as providers respond to changing payment models and market factors. A growing body of research on comparative health system performance suggests that integration of physician practices with hospitals might not be enough to achieve higher-value care. More information is needed to identify the health system attributes that contribute to improved outcomes, as well as which policy levers can minimize anticompetitive effects and maximize the benefits of these affiliations.

Rachel M. Machta, PhD, is Researcher, Mathematica Policy Research, Oakland, California. E-mail:

Kristin A. Maurer, MPH, is Research Analyst, Mathematica Policy Research, Ann Arbor, Michigan.

David J. Jones, PhD, is Associate Director, Mathematica Policy Research, Cambridge, Massachusetts.

Michael F. Furukawa, PhD, is Senior Economist, Agency for Healthcare Research and Quality, Rockville, Maryland.

Eugene C. Rich, MD, is Senior Fellow, Mathematica Policy Research, Washington, DC.

This study was funded by the Agency for Healthcare Research and Quality under contract HHSA-290-2016-00001-C. The views expressed herein are those of the authors and do not necessarily reflect those of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

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The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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