The National Survey of Healthcare Organizations and Systems (NSHOS), was developed by researchers at the Center of Excellence and fielded from June 2017-August 2018. NSHOS is a suite of nationally representative surveys that aim to characterize the structure, ownership, leadership, and care delivery capabilities of health care systems, primary and multispecialty care physician practices, and hospitals.
We identified systems, physician practices, and hospitals to sample from the health information firm, IQVIA. IQVIA's commercially available OneKey database describes relationships among physicians, practices, hospitals, and healthcare systems. IQVIA uses the American Medical Association’s physician Masterfile, publicly available sources, and proprietary data collection strategies to develop the OneKey database.
We used a stratified-cluster sampling design to select healthcare systems, physician practices, and hospitals. When a healthcare system was sampled, we then selected physician practices and hospitals owned by those systems. We stratified our sample based on ownership and composition structures including samples of both system-owned and independent physician practices and hospitals.
A specially constructed survey design was used to maximize our ability to learn from the full population of health systems and subsequently estimate statistical models that can estimate effects, capture heterogeneity, and attribute unexplained variation at multiple levels of data. We used a two-stage sampling design in which the within unit (second-stage) sampling probabilities varied across the primary sampling units (clusters). The primary-sampling units are also partially clustered in that owner-subsidiaries are always nested in corporate parents. However, many corporate parents do not have owner-subsidiaries nested within them. Thus, the design can be thought of as a two-stage probability design with multi-layered clustering and (optional) stratification by organization type (e.g., within-system versus independent hospitals and medical groups).
Health Systems
We surveyed C-suite leaders, such as a Chief Executive Officer or a Chief Medical Officer, of healthcare systems. We defined healthcare systems as organizations that owned or managed:
- one or more hospitals and one or more primary or multispecialty care physician practices, or
- no practices, but two or more hospitals, or
- no hospitals, but two or more practices
We excluded systems owned by the federal government (e.g. Indian Health Service, Veterans Affairs) and systems with a reference to specialty (e.g. cancer) in their business name. We sampled 570 health systems and obtained 341 responses.
Click here to download the system-level survey instrument
Owner Subsidiaries
Some healthcare systems included organizations, owner subsidiaries, that themselves own physician practices and/or hospitals. If the larger or parent healthcare system was sampled, then we also sent the system-level survey instrument to at least one of the system’s owner subsidiaries, and we sampled practices and hospitals included in that owner subsidiary. Similarly, if an owner subsidiary was sampled, we also sent the system-level survey instrument to the health system that owned it. At owner subsidiaries, we surveyed a C-suite or director-level leader. We sampled 222 owner subsidiaries and obtained 107 responses.
Primary and Multispecialty Care Physician Practices
We surveyed practice managers and physicians in primary and multispecialty care physician practices that had at least three primary care physicians. We defined physician practices as a single location practice. Primary care physicians included family medicine, geriatrics, internal medicine, or preventive medicine specialties. We sampled 4,976 practices and obtained 2,333 responses.
Physician Practice Sample Frame and Generalizability
Because OneKey data do not indicate whether a physician practice provides outpatient care, we used Medicare claims to assess how our sample frame compares to physicians delivering care nationwide; 93% of physicians nationwide accept Medicare patients1. In 2015, there were 51,995 primary or multispecialty care physician practices with at least 1 primary care physician delivering ambulatory care to 17.6 million fee-for-service Medicare beneficiaries. Of these practices, 15,121 (29%) had 3 or more primary care physicians, and they delivered care to 10.6 million beneficiaries, or over 60% of patients receiving ambulatory care from primary care focused practices.
Click here to download the practice-level survey instrument
Hospitals
We surveyed C-suite leaders, such as Chief Medical Officers, at short-term, acute care and critical access hospitals. We sampled 1,628 hospitals and obtained 757 responses.
Click here to download the hospital-level survey instrument
- Boccuti C, Fields C, Casillas G, Hamel L. Primary Care Physicians Accepting Medicare: A Snapshot. The Henry J. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/. Published October 30, 2015. Accessed April 9, 2019.