Peter Kralovec - Academia.edu (original) (raw)
Papers by Peter Kralovec
Objectives. To (a) assess how the original cluster categories of hospital-led health networks and... more Objectives. To (a) assess how the original cluster categories of hospital-led health networks and systems have changed over time; (b) identify any new patterns of cluster configurations; and (c) demonstrate how additional data can be used to refine and enhance the taxonomy measures.
Medical care research and review : MCRR, Jan 22, 2015
Hospital system formation has recently accelerated. Executives emphasize scale economies that low... more Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types o...
Advances in health care management, 2012
Research on hospital system organization is dated and cross-sectional. We analyze trends in syste... more Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized. We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association. There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital. Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization. Systems that appear to be able ...
The American journal of managed care, 2011
To update the status of electronic health record (EHR) adoption in US hospitals and assess their ... more To update the status of electronic health record (EHR) adoption in US hospitals and assess their readiness for "Meaningful Use" (MU). We used data from the 2010 American Hospital Association Annual Information Technology Survey. The survey was first conducted in 2007 and is made available both online and through the mail to all non-federal acute-care hospitals in the United States. We measure the percentages of applicable hospitals that have adopted "basic" and "comprehensive" EHRs as defined in previous literature. Additionally, we report the percentage of hospitals planning to apply for MU in the near term, and assess hospitals' readiness for the program and how readiness varies by key characteristics. We received responses from 2902 hospitals (64% of all non-federal acute-care hospitals). More than 15% have adopted at least a "basic" EHR, representing nearly 75% growth since 2008. Approximately two-thirds plan to apply for MU before 201...
Health affairs (Project Hope), 2014
The national effort to promote the adoption and meaningful use of electronic health records (EHRs... more The national effort to promote the adoption and meaningful use of electronic health records (EHRs) is well under way. However, 2014 marks an important transition: For many hospitals, penalties will be assessed in fiscal year 2015 for failing to meet federal meaningful-use criteria by the end of fiscal year 2014. We used recent data from the American Hospital Association Annual Survey of Hospitals--IT Supplement to assess progress and challenges. EHR adoption among US hospitals continues to rise steeply: 59 percent now have at least a basic EHR. Small and rural hospitals continue to lag behind their better resourced counterparts. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. Several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available ...
Journal of Palliative Medicine, 2001
In the United States, the majority of deaths occur in the hospital but the dying process there is... more In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.
Health Services Research, 2004
Objectives. To (a) assess how the original cluster categories of hospital-led health networks and... more Objectives. To (a) assess how the original cluster categories of hospital-led health networks and systems have changed over time; (b) identify any new patterns of cluster configurations; and (c) demonstrate how additional data can be used to refine and enhance the taxonomy measures. Data Sources. 1994 and 1998 American Hospital Association (AHA) Annual Survey of Hospitals. Study Design. As in the original taxonomy, separate cluster solutions are identified for health networks and health systems by applying three strategic/structural dimensions (differentiation, integration, and centralization) to three components of the health service/product continuum (hospital services, physician arrangements, and providerbased insurance activities). Data Extraction Methods. Factor, cluster, and discriminant analyses are used to analyze the 1998 data. Descriptive and comparative methods are used to analyze the updated 1998 taxonomy relative to the original 1994 version. Principal Findings. The 1998 cluster categories are similar to the original taxonomy, however, they reveal some new organizational configurations. For the health networks, centralization of product/service lines is occurring more selectively than in the past. For the health systems, participation has grown in and dispersed across a more diverse set of decentralized organizational forms. For both networks and systems, the definition of centralization has changed over time.
Health Care Management Review, 2000
This article illustrates how a new approach to classifying health networks and systems can be use... more This article illustrates how a new approach to classifying health networks and systems can be used to evaluate the readiness of health care organizations to accept risk. Examples are provided from the Harris-Methodist, Henry Ford, and SSM Health Care Systems. The classification system can also be used to assist executives and physician leaders in making decisions involving the centralization of services, the number of different services to offer, and decisions to enter into various strategic alliances. The classification system can be updated to help track the evolution of the U.S. health care system over time.
Health Affairs, 2013
The US health care system is in the midst of an enormous change in the way health care providers ... more The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper-based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 "meaningful-use" criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals.
Health Affairs, 2001
Throughout the 1990s health care providers were interested in developing organized delivery syste... more Throughout the 1990s health care providers were interested in developing organized delivery systems. However, industry observers have increasingly questioned the sense of these efforts. Using an established taxonomy of health networks and systems, we examined whether there was a nationwide trend away from the vertical and horizontal arrangements that serve as the backbone to organized delivery systems. Studying 1994-1998, we found that both health networks and systems became less centralized in their hospital services, physician arrangements, and insurance product development. We did not find a general pathway to disintegration but instead found considerable experimentation in organizational form.
Health Affairs, 2012
To achieve the goal of comprehensive health information record keeping and exchange among provide... more To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all.
Journal of Hospital Medicine, 2006
Hospitalists, defined as hospital-based physicians who take responsibility for managing the medic... more Hospitalists, defined as hospital-based physicians who take responsibility for managing the medical needs of inpatients, represent a significant trend in physician specialization. However, only limited anecdotal data quantifying the status of hospital medicine groups around the country is available. To better understand the extent and nature of the hospitalist movement, utilizing data from the 2003 Annual Survey of the American Hospital Association (AHA). 4895 acute care hospitals in the United States. Number and percentage of hospitals with hospital medicine groups; mean number of hospitalists per group; hospitalists per average daily census (ADC) of 100 patients; distribution of groups by employment model. DESCRIPTIVE VARIABLES: Census region; rural/urban status; number of beds; organizational control; teaching status. There are approximately 1415 hospital medicine groups and 11,159 hospitalists in the United States. The overall penetration of hospital medicine groups at hospitals is 29% (55% at hospitals with 200 or more beds), and the in-hospital impact at hospitals with hospital medicine groups is 3.93 hospitalists per 100 ADC. The average hospital medicine group has 7.9 hospitalists. There is a fairly equal distribution among the 3 major employment models for hospital medicine groups: hospital employees, independent provider groups, and physician groups. All these measures can vary substantially, depending on the characteristics of individual hospitals. Hospital medicine appears to have become part of the mainstream delivery of health care in the United States. No employment model of hospital medicine group appears to dominate this specialty. We expect there will continue to be growth and diversity in the implementation of hospital medicine groups.
Objectives. To (a) assess how the original cluster categories of hospital-led health networks and... more Objectives. To (a) assess how the original cluster categories of hospital-led health networks and systems have changed over time; (b) identify any new patterns of cluster configurations; and (c) demonstrate how additional data can be used to refine and enhance the taxonomy measures.
Medical care research and review : MCRR, Jan 22, 2015
Hospital system formation has recently accelerated. Executives emphasize scale economies that low... more Hospital system formation has recently accelerated. Executives emphasize scale economies that lower operating costs, a claim unsupported in academic research. Do systems achieve lower costs than freestanding facilities, and, if so, which system types? We test hypotheses about the relationship of cost with membership in systems, larger systems, and centralized and local hub-and-spoke systems. We also test whether these relationships have changed over time. Examining 4,000 U.S. hospitals during 1998 to 2010, we find no evidence that system members exhibit lower costs. However, members of smaller systems are lower cost than larger systems, and hospitals in centralized systems are lower cost than everyone else. There is no evidence that the system's spatial configuration is associated with cost, although national system hospitals exhibit higher costs. Finally, these results hold over time. We conclude that while systems in general may not be the solution to lower costs, some types o...
Advances in health care management, 2012
Research on hospital system organization is dated and cross-sectional. We analyze trends in syste... more Research on hospital system organization is dated and cross-sectional. We analyze trends in system structure during 2000-2010 to ascertain whether they have become more centralized or decentralized. We test hypotheses drawn from organization theory and estimate empirical models to study the structural transitions that systems make between different "clusters" defined by the American Hospital Association. There is a clear trend toward system fragmentation during most of this period, with a small recent shift to centralization in some systems. Systems decentralize as they increase their members and geographic dispersion. This is particularly true for systems that span multiple states; it is less true for smaller regional systems and local systems that adopt a hub-and-spoke configuration around a teaching hospital. Our time series ends in 2010 just as health care reform was implemented. We also rely on a single measure of system centralization. Systems that appear to be able ...
The American journal of managed care, 2011
To update the status of electronic health record (EHR) adoption in US hospitals and assess their ... more To update the status of electronic health record (EHR) adoption in US hospitals and assess their readiness for "Meaningful Use" (MU). We used data from the 2010 American Hospital Association Annual Information Technology Survey. The survey was first conducted in 2007 and is made available both online and through the mail to all non-federal acute-care hospitals in the United States. We measure the percentages of applicable hospitals that have adopted "basic" and "comprehensive" EHRs as defined in previous literature. Additionally, we report the percentage of hospitals planning to apply for MU in the near term, and assess hospitals' readiness for the program and how readiness varies by key characteristics. We received responses from 2902 hospitals (64% of all non-federal acute-care hospitals). More than 15% have adopted at least a "basic" EHR, representing nearly 75% growth since 2008. Approximately two-thirds plan to apply for MU before 201...
Health affairs (Project Hope), 2014
The national effort to promote the adoption and meaningful use of electronic health records (EHRs... more The national effort to promote the adoption and meaningful use of electronic health records (EHRs) is well under way. However, 2014 marks an important transition: For many hospitals, penalties will be assessed in fiscal year 2015 for failing to meet federal meaningful-use criteria by the end of fiscal year 2014. We used recent data from the American Hospital Association Annual Survey of Hospitals--IT Supplement to assess progress and challenges. EHR adoption among US hospitals continues to rise steeply: 59 percent now have at least a basic EHR. Small and rural hospitals continue to lag behind their better resourced counterparts. Most hospitals are able to meet many of the stage 2 meaningful-use criteria, but only 5.8 percent of hospitals are able to meet them all. Several criteria, including sharing care summaries with other providers and providing patients with online access to their data, will require attention from EHR vendors to ensure that the necessary functions are available ...
Journal of Palliative Medicine, 2001
In the United States, the majority of deaths occur in the hospital but the dying process there is... more In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.
Health Services Research, 2004
Objectives. To (a) assess how the original cluster categories of hospital-led health networks and... more Objectives. To (a) assess how the original cluster categories of hospital-led health networks and systems have changed over time; (b) identify any new patterns of cluster configurations; and (c) demonstrate how additional data can be used to refine and enhance the taxonomy measures. Data Sources. 1994 and 1998 American Hospital Association (AHA) Annual Survey of Hospitals. Study Design. As in the original taxonomy, separate cluster solutions are identified for health networks and health systems by applying three strategic/structural dimensions (differentiation, integration, and centralization) to three components of the health service/product continuum (hospital services, physician arrangements, and providerbased insurance activities). Data Extraction Methods. Factor, cluster, and discriminant analyses are used to analyze the 1998 data. Descriptive and comparative methods are used to analyze the updated 1998 taxonomy relative to the original 1994 version. Principal Findings. The 1998 cluster categories are similar to the original taxonomy, however, they reveal some new organizational configurations. For the health networks, centralization of product/service lines is occurring more selectively than in the past. For the health systems, participation has grown in and dispersed across a more diverse set of decentralized organizational forms. For both networks and systems, the definition of centralization has changed over time.
Health Care Management Review, 2000
This article illustrates how a new approach to classifying health networks and systems can be use... more This article illustrates how a new approach to classifying health networks and systems can be used to evaluate the readiness of health care organizations to accept risk. Examples are provided from the Harris-Methodist, Henry Ford, and SSM Health Care Systems. The classification system can also be used to assist executives and physician leaders in making decisions involving the centralization of services, the number of different services to offer, and decisions to enter into various strategic alliances. The classification system can be updated to help track the evolution of the U.S. health care system over time.
Health Affairs, 2013
The US health care system is in the midst of an enormous change in the way health care providers ... more The US health care system is in the midst of an enormous change in the way health care providers and hospitals document, monitor, and share information about health and care delivery. Part of this transition involves a wholesale, but currently uneven, shift from paper-based records to electronic health record (EHR) systems. We used the most recent longitudinal survey of US hospitals to track how they are adopting and using EHR systems. Only 44 percent of hospitals report having and using what we define as at least a basic EHR system. And although 42.2 percent meet all of the federal stage 1 "meaningful-use" criteria, only 5.1 percent could meet the broader set of stage 2 criteria. Large urban hospitals continue to outpace rural and nonteaching hospitals in adopting EHR systems. The increase in adoption overall suggests that the positive and negative financial incentives currently in place across the US health care system are working as intended. However, achieving a nationwide health information technology infrastructure may require efforts targeted at smaller and rural hospitals.
Health Affairs, 2001
Throughout the 1990s health care providers were interested in developing organized delivery syste... more Throughout the 1990s health care providers were interested in developing organized delivery systems. However, industry observers have increasingly questioned the sense of these efforts. Using an established taxonomy of health networks and systems, we examined whether there was a nationwide trend away from the vertical and horizontal arrangements that serve as the backbone to organized delivery systems. Studying 1994-1998, we found that both health networks and systems became less centralized in their hospital services, physician arrangements, and insurance product development. We did not find a general pathway to disintegration but instead found considerable experimentation in organizational form.
Health Affairs, 2012
To achieve the goal of comprehensive health information record keeping and exchange among provide... more To achieve the goal of comprehensive health information record keeping and exchange among providers and patients, hospitals must have functioning electronic health record systems that contain patient demographics, care histories, lab results, and more. Using national survey data on US hospitals from 2011, the year federal incentives for the meaningful use of electronic health records began, we found that the share of hospitals with any electronic health record system increased from 15.1 percent in 2010 to 26.6 percent in 2011, and the share with a comprehensive system rose from 3.6 percent to 8.7 percent. The proportion able to meet our proxy criteria for meaningful use also rose; in 2011, 18.4 percent of hospitals had these functions in place in at least one unit and 11.2 percent had them across all clinical units. However, gaps in rates of adoption of at least a basic record system have increased substantially over the past four years based on hospital size, teaching status, and location. Small, nonteaching, and rural hospitals continue to adopt electronic health record systems more slowly than other types of hospitals. In sum, this is mixed news for policy makers, who should redouble their efforts among hospitals that appear to be moving slowly and ensure that policies do not further widen gaps in adoption. A more robust infrastructure for information exchange needs to be developed, and possibly a special program for the sizable minority of hospitals that have almost no health information technology at all.
Journal of Hospital Medicine, 2006
Hospitalists, defined as hospital-based physicians who take responsibility for managing the medic... more Hospitalists, defined as hospital-based physicians who take responsibility for managing the medical needs of inpatients, represent a significant trend in physician specialization. However, only limited anecdotal data quantifying the status of hospital medicine groups around the country is available. To better understand the extent and nature of the hospitalist movement, utilizing data from the 2003 Annual Survey of the American Hospital Association (AHA). 4895 acute care hospitals in the United States. Number and percentage of hospitals with hospital medicine groups; mean number of hospitalists per group; hospitalists per average daily census (ADC) of 100 patients; distribution of groups by employment model. DESCRIPTIVE VARIABLES: Census region; rural/urban status; number of beds; organizational control; teaching status. There are approximately 1415 hospital medicine groups and 11,159 hospitalists in the United States. The overall penetration of hospital medicine groups at hospitals is 29% (55% at hospitals with 200 or more beds), and the in-hospital impact at hospitals with hospital medicine groups is 3.93 hospitalists per 100 ADC. The average hospital medicine group has 7.9 hospitalists. There is a fairly equal distribution among the 3 major employment models for hospital medicine groups: hospital employees, independent provider groups, and physician groups. All these measures can vary substantially, depending on the characteristics of individual hospitals. Hospital medicine appears to have become part of the mainstream delivery of health care in the United States. No employment model of hospital medicine group appears to dominate this specialty. We expect there will continue to be growth and diversity in the implementation of hospital medicine groups.