LAUSR

TO THE EDITOR: Scott and colleagues' findings (1) are not particularly surprising. Employment by hospital systems alone does not necessarily affect the quality of care provided. Belief that it does is partly based on the authors' false assumption that hospital-employed physicians are less likely to focus on generating revenue to maintain an independent practice and more likely to focus on patient care. This statement seems to assume that these employment arrangements are based on salary rather than productivity. In general, physician employment agreements with hospitals remain largely productivity-based (dependent on, for example, encounters and work relative value units). On the basis of our group's participation in a national survey of large affiliated groups, approximately 90% of physician compensation remains productivity-based, whereas 10% is value-based (dependent on, for example, patient satisfaction, citizenship, and quality metrics). To date, the primary driver for hospital systems to employ physicians is to ensure that these systems have a more stable revenue stream. Most physicians coming out of training are not looking for positions in private practice, with all of its administrative hassles; therefore, physicians who have embraced private practice cannot easily recruit or retain physicians. At the same time, many physicians in private practice are finding the business and regulatory burdens untenable and are looking for hospital systemaffiliated employment opportunities. As such, for hospital systems, physician employment seems primarily a matter of financial survival. Although the pursuit of quality is noble, it is not the primary driver of the affiliation changes that Scott and colleagues describe. In my experience, the pursuit of improved quality of care is not magic. It does not arise spontaneously out of an employment agreement. What is required is time and attention, usually from a team of persons who can understand processes and workflows, perform gap analyses, and use various tools inherent to process improvement. In general, if you want physicians to participate in this process, you need to offset reduction in income based on lower productivity with a stipend that covers their lost opportunity. As Scott and colleagues note, by employing physicians, hospitals can more closely direct their activities and drive changes in care. With largely productivity-based employment agreements, for that to happen hospital systems must be willing to separately reimburse physicians for those activities.