All ETDs from UAB

Advisory Committee Chair

Larry R Hearld

Advisory Committee Members

Nathaniel Carroll

Stephen J O'Connor

Mary D Peterson

Bisakha Sen

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Health Professions


The rise and fall of managed care in the 1980s and 1990s saw many hospitals and health systems in the United States enter and subsequently exit the health insurance market in the form of provider-sponsored health plans (PSHP). The passage and implementation of the legislation such as the Patient Protection and Affordable Care Act (ACA) and the Medicare Access and CHIP Reauthorization Act (MACRA) has ushered in an era of value-based reimbursement methods and a heightened focus on population health management, which has stimulated health care organizations to contemplate health plan ownership as a logical strategy. This study examined market and organizational factors associated with PSHP ownership, how organizational learning and absorptive capacity are associated with health plan ownership, and how PSHP is associated with performance on coordination of care and readmissions measures. This study used a sequential quantitative to qualitative mixed-methods design. The quantitative analysis examined 5,849 U.S. hospitals using binary logistic regression and ordinary least squares regression models for the year 2017. For the qualitative portion, ten semi-structured interviews were conducted with health system or health plan executives representing eight health systems in five states. Thematic analysis was conducted to identify common themes across interviews, and results were synthesized with quantitative findings. The results indicated that hospital and payer concentration, percentage of the state population on Medicare, income per capita, unemployment rate, presence of salaried physicians at the hospital, participation in risk-bearing arrangements, absorptive capacity score, and participation in a clinically integrated network, as well as profit-status and CBSA indicator were all significantly associated with health plan ownership at p<.05. Hospitals with a health plan did not perform better on coordination of care measures captured through the HCAHPS survey but did have lower unplanned readmissions and fewer unplanned days in the hospital post-discharge at p<.05. Interviewees reinforced these findings and described PSHP as the culmination of the journey along the continuum of volume-based incentives to value-based incentives, as well as a strategy to better compete, diversify revenue streams, and a mechanism for learning and improving patient care. Implications for policy and practice are discussed.



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