Organization and Performance of US Health Systems | Health Care Reform | JAMA

<!DOCTYPE html> <html id="doc" lang="en" class="page-abstract"> <head id="Head1">  <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <script> var SCM = SCM || {}; if (SCM.AMA && SCM.AMA.DataLayerAsync) { SCM.AMA.DataLayerAsync.push("arrSisAffinity", "", "array"); SCM.AMA.DataLayerAsync.push("SubStatus", "no", "string"); } var googletag = window.googletag || {}; googletag.cmd = googletag.cmd || []; if (typeof Storage !== "undefined") { var targetingParamStr = localStorage.getItem("bcDFPTargetingParams"); if (targetingParamStr) { var targetingParameters = JSON.parse(targetingParamStr); // set page-level targeting parameters jQuery.each(targetingParameters, function (index, param) { googletag.cmd.push(function () { window.googletag.pubads().setTargeting(param.key, param.value); }); }); } } if (!googletag.pubads) { (function () { var gads = document.createElement('script'); var useSSL = 'https:' == document.location.protocol; gads.src = (useSSL ? 'https:' : 'http:') + '//securepubads.g.doubleclick.net/tag/js/gpt.js'; gads.setAttribute("async", ""); gads.setAttribute("defer", ""); var node = document.getElementsByTagName('script')[0]; node.parentNode.insertBefore(gads, node); })(); var App = App || {}; App.Ads = App.Ads || {}; App.Ads.adPath = App.Ads.adPath || '/6479/' + 'ama.jama'; App.Ads.Mappings = App.Ads.Mappings || {}; App.Ads.slots = App.Ads.slots || []; App.Ads.fromGoogle = !('yes' === 'yes'); App.isCollection = App.isCollection || !!document.getElementsByClassName('pg_collection').length; googletag.cmd.push(function () { googletag.pubads() .setTargeting('environment', ['newjama']) .setTargeting('site', ['ama.jama']) .setTargeting('sect', ['abstract']) .setTargeting('sub', ['no']) .setTargeting('device', ['Mozilla%2F4.0%20%28compatible%3B%20MSIE%207.0%3B%20Windows%20NT%206.0%3B%20SLCC1%3B%20.NET%20CLR%202.0.50727%3B%20.NET%20CLR%203.0.04506%3B%20.NET%20CLR%203.5.21022%3B%20.NET%20CLR%201.0.3705%3B%20.NET%20CLR%201.1.4322%29']) .setTargeting('usaphys', ['no']) .setTargeting('memberstat', ['no']) .setTargeting('pracset', ['']) .setTargeting('specialty', ['other']) .setTargeting('occupation', ['']) .setTargeting('useraffinity', ['']) .setTargeting('direct', ['yes']) .setTargeting('bot', ['']) .setTargeting('datacenter', ['no']) .setTargeting('selfMPA', ['']) .setTargeting('selfSpecialty', ['']); if (App.isCollection) { googletag.pubads().setTargeting('collection', ['']); } var testParam = getQueryVariable('test'); if (testParam) { googletag.pubads().setTargeting('test', [testParam]); } function getQueryVariable(variable) { var query = window.location.search.substring(1); var vars = query.split('&'); for (var i = 0; i < vars.length; i++) { var pair = vars[i].split('='); if (decodeURIComponent(pair[0]) == variable) { return decodeURIComponent(pair[1]); } } } googletag.pubads().disableInitialLoad(); googletag.enableServices(); }); } </script> <meta name="viewport" content="width=device-width, initial-scale=1" /><meta name="format-detection" content="telephone=no" /><link rel="shortcut icon" href="//cdn.jamanetwork.com/UI/app/img/favicons/jama/favicon.ico"> <link rel="icon" type="image/png" href="//cdn.jamanetwork.com/UI/app/img/favicons/jama/favicon-192x192.png" sizes="192x192"> <link rel="apple-touch-icon" sizes="180x180" href="//cdn.jamanetwork.com/UI/app/img/favicons/jama/apple-touch-icon-180x180.png"> <meta http-equiv="X-UA-Compatible" content="IE=Edge" /> <link rel="stylesheet" href="//cdn.jamanetwork.com/UI/app/dist/app.min.css?v=638677764476993385"> <link href="//cdn.jsdelivr.net/chartist.js/latest/chartist.min.css" type="text/css" rel="stylesheet" /> <meta property="og:title" content="Organization and Performance of US Health Systems" /> <meta property="og:type" content="Article" /> <meta property="og:url" content="https://jamanetwork.com/journals/jama/fullarticle/2800656" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008f1_1674242688.25598.png?Expires=2147483647&Signature=DT~fjXkwSC~Im~bpHRVsSLWfV0RryCpIcFXvpiqVMl6-3XweNHbQmOanoJvmVMxUVIAvs9xNo4t8w7iPkNQhqwjsVI9Ds5WgD4dhL8H6FbARHO51JFMtu6M~5vo0RQatUH3KknmSO~MUQay3gkswWc7KJrK2ZdSLp8BfYRwEh~9SuXmJfLdwnslKlxbR11DpLKN5Jahmt8JLUQq~ksK-w4nk1HCsto039PHTwpMLzaYiY8z-okBaN4yKmU2AugecbJoRgWi0fphk83aEyD~vUQ8LuEavsH1YeCCW-fUxEmpsrSevG8qFQq2MR0j2DmzrvSWGSk-MKFRAo8FW9lYWhA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008f2_1674242688.28096.png?Expires=2147483647&Signature=3bdli5Bd1iDrOw5njjH1LmWLPvaScxdOMzW-icpacNyfz08cJU9ohpD3wUZh6EDCaw1FbwVOpkEjdxofpmr53rXilbxzSzwa8m0D4C7W0gA2nUF0-K9JccDLF-iIoNH1LenK~s8TFm1MMvCACq0-JTUeShNN8Hu1epVnvNboJDjatOAGFYP-dl6~L5Nly8LrFTWJIdozfzEETm4WdH-PrU1sFyHOL8pXD2xRYFRzKoAct1uFNsi-arDGbUbsdaH4dXNeg~oEXErFNwVpDpJnCQHcdjPu20U3wi6I4hIGCnWT2PR4p1ZHZnPl7rQbUKcihXW9u3guYYKjUs29Hgv9Yw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t1_1674242688.30092.png?Expires=2147483647&Signature=FNHRxTIxdUV1aq~04wUwgHu9MFBpF9qBuen5cuz~4glnRdm8s~QcaMrWnEZWhntzJdXRyI3GJ-6sP75-BsyNoaw1AZLCZ~aScic3RLWCApERG~ofOoI1IoteBymStVSDSSoHcOvr2BZC8QolGbpdLM883mObPrIrKoTj8ibyEUbOiC-xqe1NXoUyuP1xa2uoYxOxgqoa6IrL7OERq1oTAuqy0lWByEfNItxDmhFNR1yGXxItqSfXPDg3m7Wq2RERFr7hZzB4e2wcOZoFs6P~TcHZFjQr4Q2WTDI9tcu1Jn3WZRGb56SsIyK5bc-qYqi00nM02YBdXyPbhMLK3VRoww__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t2_1674242688.36097.png?Expires=2147483647&Signature=v8hFJ5oZIY6BfyUsiNagcV-fRds~KC3grJJ1Y9of-zra7psx-1JPh0KXjEvQABudlUq43Ei8ZpX1YqCXTvKfeqtlbMOFqwzQmHHvye-w~QHv8sU0CWElJzvjAq5tKSHXEjYAVP5c5Aqs~qKaCAZI2Sltf7VskMX8Do6v7abwZx9hbSxN954lDeHXliQj~raAunoL2A3R9J0qiPcCu-F4XuWKo~1Vl9leG2MtZVtUo~0STOULgK416c0JcClWO6PSzX45cK77cgGhDAjpu5Z63Jq-eyJd3QwGRPZTUqicPqiPxUtLBTLw1PBZVZIAjdu91hK85CxF0b1TLypuWQ6CCg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t3_1674242688.39094.png?Expires=2147483647&Signature=aq-b3As1SMayNDnaxAWf2xymtYTajIPeI6aCAcNS~R-GrhUC2fyygjMzxqWVC6ATn~wRBo3XeMT6unoWrqbaMd1msCO1xAl2C0R68Hns74vFqViDzPUROSCKmleyGbWlXqDR~rNpBNlQfHIfparOtjG060xIgwXhFKu4D-0Z8ghmEOZd6584ECsmrImNcXL-mZ6~vFO-IjrXORFKY8AS8DratqGZIkAz6uoq9fHz505nplkAh8VWE7UStKDN8~N-0u5ymYNrDXtgMSu62PYm4WWAflaXeoCBxvJDtPgLGuR0THE5huyzka5tJsyru9oBSC8m3M~UCllyihVvQBZNCQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta property="og:description" content="This Special Communication examines health systems in the United States, assesses differences between physicians and hospitals in and outside of health systems, and compares quality and cost of care delivered by physicians and hospitals in and outside of health systems." /> <meta property="fb:pages" content="87087958340" /> <meta property="fb:pages" content="122228711814384" /> <meta property="fb:pages" content="1648414928738217" /> <meta property="fb:pages" content="117506346528" /> <meta property="fb:pages" content="97538728726" /> <meta property="fb:pages" content="114116793520" /> <meta property="fb:pages" content="100679858757" /> <meta property="fb:pages" content="759822190741773" /> <meta property="fb:pages" content="100265333750" /> <meta property="fb:pages" content="234770525256" /> <meta property="fb:pages" content="98784919862" /> <meta property="fb:pages" content="120829458202" /> <meta property="fb:pages" content="124842870398" /> <meta property="fb:pages" content="110245330325636" /> <meta name="twitter:card" content="summary_large_image" /> <meta name="twitter:site" content="@JAMA_current" /> <meta name="twitter:image" content="https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008f1_1674242688.25598.png?Expires=2147483647&Signature=DT~fjXkwSC~Im~bpHRVsSLWfV0RryCpIcFXvpiqVMl6-3XweNHbQmOanoJvmVMxUVIAvs9xNo4t8w7iPkNQhqwjsVI9Ds5WgD4dhL8H6FbARHO51JFMtu6M~5vo0RQatUH3KknmSO~MUQay3gkswWc7KJrK2ZdSLp8BfYRwEh~9SuXmJfLdwnslKlxbR11DpLKN5Jahmt8JLUQq~ksK-w4nk1HCsto039PHTwpMLzaYiY8z-okBaN4yKmU2AugecbJoRgWi0fphk83aEyD~vUQ8LuEavsH1YeCCW-fUxEmpsrSevG8qFQq2MR0j2DmzrvSWGSk-MKFRAo8FW9lYWhA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" /> <meta name="citation_author" content="Nancy D. Beaulieu" /><meta name="citation_author_institution" content="Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="Michael E. Chernew" /><meta name="citation_author_institution" content="Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="J. Michael McWilliams" /><meta name="citation_author_institution" content="Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author_institution" content="Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts" /><meta name="citation_author" content="Mary Beth Landrum" /><meta name="citation_author_institution" content="Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="Maurice Dalton" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Angela Yutong Gu" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Michael Briskin" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Rachel Wu" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Zakaria El Amrani El Idrissi" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Helene Machado" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author" content="Andrew L. Hicks" /><meta name="citation_author_institution" content="Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts" /><meta name="citation_author" content="David M. Cutler" /><meta name="citation_author_institution" content="National Bureau of Economic Research, Cambridge, Massachusetts" /><meta name="citation_author_institution" content="Department of Economics, Harvard University, Cambridge, Massachusetts" /><meta name="citation_title" content="Organization and Performance of US Health Systems" /><meta name="citation_firstpage" content="325" /><meta name="citation_lastpage" content="335" /><meta name="citation_doi" content="10.1001/jama.2022.24032" /><meta name="citation_keyword" content="health care systems" /><meta name="citation_keyword" content="medicare" /><meta name="citation_abstract" content="<h3>Importance</h3><p>Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.</p><h3>Objective</h3><p>To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.</p><h3>Evidence Review</h3><p>Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare &amp; Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.</p><h3>Findings</h3><p>A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with &gt;100 beds), as were system physician practices (74% vs 12% with &gt;100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.</p><h3>Conclusions and Relevance</h3><p>In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.</p>" /><meta name="citation_journal_title" content="JAMA" /><meta name="citation_journal_abbrev" content="JAMA" /><meta name="citation_volume" content="329" /><meta name="citation_issue" content="4" /><meta name="citation_publication_date" content="2023/01/24" /><meta name="citation_issn" content="0098-7484" /><meta name="citation_publisher" content="American Medical Association" /><meta name="citation_reference" content="citation_title=Hospital-physician consolidation accelerated in the past decade in cardiology, oncology.; citation_author=Nikpay SS; citation_author=Richards MR; citation_author=Penson D; citation_journal_title=Health Aff (Millwood); citation_year=2018; citation_volume=37; citation_issue=7; citation_pages=1123-1127; " /><meta name="citation_reference" content="citation_title=Consolidation of providers into health systems increased substantially, 2016-18.; citation_author=Furukawa MF; citation_author=Kimmey L; citation_author=Jones DJ; citation_author=Machta RM; citation_author=Guo J; citation_author=Rich EC; citation_journal_title=Health Aff (Millwood); citation_year=2020; citation_volume=39; citation_issue=8; citation_pages=1321-1325; " /><meta name="citation_reference" content="citation_title=Health care market concentration trends in the United States: evidence and policy responses.; citation_author=Fulton BD; citation_journal_title=Health Aff (Millwood); citation_year=2017; citation_volume=36; citation_issue=9; citation_pages=1530-1538; " /><meta name="citation_reference" content="Gaynor M. Health care industry consolidation: statement before the Committee on Ways and Means Health Subcommittee of the US House of Representatives. September 9, 2011. Accessed October 21, 2020. https://www.researchgate.net/publication/287266587_Statement_of_Martin_Gaynor_professor_Carnegie_Mellon_University_Hearing_on_health_care_industry_consolidation " /><meta name="citation_reference" content="Physician Advocacy Institute. PAI-Avalere health report on trends in physician employment and acquisitions of medical practices: 2019-2021. Accessed May 26, 2022. http://www.physiciansadvocacyinstitute.org/PAI-Research/Physician-Employment-and-Practice-Acquisitions-Trends-2019-21 " /><meta name="citation_reference" content="citation_title=The promise and peril of health systems.; citation_author=Kronick R; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1027-1030; " /><meta name="citation_reference" content="citation_author=Goldsmith J; citation_author=Burns LR; citation_author=Sen A; citation_author=Goldsmith T; citation_publisher=National Academy of Social Insurance, ; citation_title=Integrated Delivery Networks: In Search of Benefits and Market Effects; citation_year=2015; " /><meta name="citation_reference" content="citation_title=Provider consolidation and potential efficiency gains: a review of theory and evidence.; citation_author=Neprash HT; citation_author=McWilliams JM; citation_journal_title=Antitrust Law J; citation_year=2019; citation_volume=82; citation_issue=2; citation_pages=551-578; " /><meta name="citation_reference" content="citation_title=Vertical integration of hospitals and physicians: economic theory and empirical evidence on spending and quality.; citation_author=Post B; citation_author=Buchmueller T; citation_author=Ryan AM; citation_journal_title=Med Care Res Rev; citation_year=2018; citation_volume=75; citation_issue=4; citation_pages=399-433; " /><meta name="citation_reference" content="citation_title=Medical group characteristics and the cost and quality of care for Medicare beneficiaries.; citation_author=Casalino LP; citation_author=Ramsay P; citation_author=Baker LC; citation_author=Pesko MF; citation_author=Shortell SM; citation_journal_title=Health Serv Res; citation_year=2018; citation_volume=53; citation_issue=6; citation_pages=4970-4996; " /><meta name="citation_reference" content="citation_title=The relationships of physician practice characteristics to quality of care and costs.; citation_author=Kralewski J; citation_author=Dowd B; citation_author=Knutson D; citation_author=Tong J; citation_author=Savage M; citation_journal_title=Health Serv Res; citation_year=2015; citation_volume=50; citation_issue=3; citation_pages=710-729; " /><meta name="citation_reference" content="citation_title=Are changes in medical group practice characteristics over time associated with Medicare spending and quality of care?; citation_author=Baker LC; citation_author=Pesko M; citation_author=Ramsay P; citation_author=Casalino LP; citation_author=Shortell SM; citation_journal_title=Med Care Res Rev; citation_year=2020; citation_volume=77; citation_issue=5; citation_pages=402-415; " /><meta name="citation_reference" content="citation_title=Delivery system integration and health care spending and quality for Medicare beneficiaries.; citation_author=McWilliams JM; citation_author=Chernew ME; citation_author=Zaslavsky AM; citation_author=Hamed P; citation_author=Landon BE; citation_journal_title=JAMA Intern Med; citation_year=2013; citation_volume=173; citation_issue=15; citation_pages=1447-1456; " /><meta name="citation_reference" content="citation_title=Vertical integration: hospital ownership of physician practices is associated with higher prices and spending.; citation_author=Baker LC; citation_author=Bundorf MK; citation_author=Kessler DP; citation_journal_title=Health Aff (Millwood); citation_year=2014; citation_volume=33; citation_issue=5; citation_pages=756-763; " /><meta name="citation_reference" content="citation_title=Higher Medicare spending on imaging and lab services after primary care physician group vertical integration.; citation_author=Whaley CM; citation_author=Zhao X; citation_author=Richards M; citation_author=Damberg CL; citation_journal_title=Health Aff (Millwood); citation_year=2021; citation_volume=40; citation_issue=5; citation_pages=702-709; " /><meta name="citation_reference" content="citation_title=Association of financial integration between physicians and hospitals with commercial health care prices.; citation_author=Neprash HT; citation_author=Chernew ME; citation_author=Hicks AL; citation_author=Gibson T; citation_author=McWilliams JM; citation_journal_title=JAMA Intern Med; citation_year=2015; citation_volume=175; citation_issue=12; citation_pages=1932-1939; " /><meta name="citation_reference" content="citation_title=How vertical integration affects the quantity and cost of care for Medicare beneficiaries.; citation_author=Koch TG; citation_author=Wendling BW; citation_author=Wilson NE; citation_journal_title=J Health Econ; citation_year=2017; citation_volume=52; citation_pages=19-32; " /><meta name="citation_reference" content="citation_title=The effect of hospital acquisitions of physician practices on prices and spending.; citation_author=Capps C; citation_author=Dranove D; citation_author=Ody C; citation_journal_title=J Health Econ; citation_year=2018; citation_volume=59; citation_pages=139-152; " /><meta name="citation_reference" content="citation_title=The impact of provider consolidation on physician prices.; citation_author=Carlin CS; citation_author=Feldman R; citation_author=Dowd B; citation_journal_title=Health Econ; citation_year=2017; citation_volume=26; citation_issue=12; citation_pages=1789-1806; " /><meta name="citation_reference" content="citation_title=Small primary care physician practices have low rates of preventable hospital admissions.; citation_author=Casalino LP; citation_author=Pesko MF; citation_author=Ryan AM; citation_journal_title=Health Aff (Millwood); citation_year=2014; citation_volume=33; citation_issue=9; citation_pages=1680-1688; " /><meta name="citation_reference" content="citation_title=Trends in hospital ownership of physician practices and the effect on processes to improve quality.; citation_author=Bishop TF; citation_author=Shortell SM; citation_author=Ramsay PP; citation_author=Copeland KR; citation_author=Casalino LP; citation_journal_title=Am J Manag Care; citation_year=2016; citation_volume=22; citation_issue=3; citation_pages=172-176; " /><meta name="citation_reference" content="citation_title=The effects of physician and hospital integration on Medicare beneficiaries’ health outcomes.; citation_author=Koch TG; citation_author=Wendling BW; citation_author=Wilson NE; citation_journal_title=Rev Econ Stat; citation_year=2021; citation_volume=103; citation_issue=4; citation_pages=725-739; " /><meta name="citation_reference" content="citation_title=Changes in quality of care after hospital mergers and acquisitions.; citation_author=Beaulieu ND; citation_author=Dafny LS; citation_author=Landon BE; citation_author=Dalton JB; citation_author=Kuye I; citation_author=McWilliams JM; citation_journal_title=N Engl J Med; citation_year=2020; citation_volume=382; citation_issue=1; citation_pages=51-59; " /><meta name="citation_reference" content="citation_title=Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries.; citation_author=Colla C; citation_author=Yang W; citation_author=Mainor AJ; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1085-1097; " /><meta name="citation_reference" content="citation_title=Financial integration’s impact on care delivery and payment reforms: a survey of hospitals and physician practices.; citation_author=Fisher ES; citation_author=Shortell SM; citation_author=O’Malley AJ; citation_journal_title=Health Aff (Millwood); citation_year=2020; citation_volume=39; citation_issue=8; citation_pages=1302-1311; " /><meta name="citation_reference" content="citation_title=Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs.; citation_author=Kranz AM; citation_author=DeYoreo M; citation_author=Eshete-Roesler B; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1118-1128; " /><meta name="citation_reference" content="citation_title=Access, quality, and financial performance of rural hospitals following health system affiliation.; citation_author=O’Hanlon CE; citation_author=Kranz AM; citation_author=DeYoreo M; citation_author=Mahmud A; citation_author=Damberg CL; citation_author=Timbie J; citation_journal_title=Health Aff (Millwood); citation_year=2019; citation_volume=38; citation_issue=12; citation_pages=2095-2104; " /><meta name="citation_reference" content="citation_title=Primary care quality and cost for privately insured patients in and out of US health systems: evidence from four states.; citation_author=Zhou RA; citation_author=Beaulieu ND; citation_author=Cutler D; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1098-1106; " /><meta name="citation_reference" content="citation_title=What defines a high-performing health care delivery system: a systematic review.; citation_author=Ahluwalia SC; citation_author=Damberg CL; citation_author=Silverman M; citation_author=Motala A; citation_author=Shekelle PG; citation_journal_title=Jt Comm J Qual Patient Saf; citation_year=2017; citation_volume=43; citation_issue=9; citation_pages=450-459; " /><meta name="citation_reference" content="citation_title=Can vertically integrated health systems provide greater value: the case of hospitals under the comprehensive care for joint replacement model?; citation_author=Machta RM; citation_author=Reschovsky J; citation_author=Jones DJ; citation_author=Furukawa MF; citation_author=Rich EC; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=4; citation_pages=541-547; " /><meta name="citation_reference" content="citation_title=Organizational influences on healthcare system adoption and use of advanced health information technology capabilities.; citation_author=Norton PT; citation_author=Rodriguez HP; citation_author=Shortell SM; citation_author=Lewis VA; citation_journal_title=Am J Manag Care; citation_year=2019; citation_volume=25; citation_issue=1; citation_pages=e21-e25; " /><meta name="citation_reference" content="citation_title=Physician practice transitions to system ownership do not result in diminished practice responsiveness to patients.; citation_author=Poon BY; citation_author=Shortell S; citation_author=Rodriguez HP; citation_journal_title=Health Serv Res; citation_year=2018; citation_volume=53; citation_issue=4; citation_pages=2268-2284; " /><meta name="citation_reference" content="citation_title=Adoption of patient-reported outcomes by health systems and physician practices in the USA.; citation_author=Rodriguez HP; citation_author=Kyalwazi MJ; citation_author=Lewis VA; citation_author=Rubio K; citation_author=Shortell SM; citation_journal_title=J Gen Intern Med; citation_year=2022; citation_volume=37; citation_issue=15; citation_pages=3885-3892; " /><meta name="citation_reference" content="citation_title=Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations.; citation_author=Timbie JW; citation_author=Kranz AM; citation_author=DeYoreo M; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1107-1117; " /><meta name="citation_reference" content="Dartmouth Atlas Project. Research methods. Accessed November 2, 2022. https://www.dartmouthatlas.org/research-methods/ " /><meta name="citation_reference" content="Agency for Healthcare Research and Quality. Comparative Health System Performance Initiative. Accessed October 21, 2022. https://www.ahrq.gov/chsp/chsp-reports/resources-for-understanding-health-systems/defining-health-systems.html " /><meta name="citation_reference" content="citation_title=Low-value service use in provider organizations.; citation_author=Schwartz AL; citation_author=Zaslavsky AM; citation_author=Landon BE; citation_author=Chernew ME; citation_author=McWilliams JM; citation_journal_title=Health Serv Res; citation_year=2018; citation_volume=53; citation_issue=1; citation_pages=87-119; " /><meta name="citation_reference" content="citation_title=Health system integration with physician specialties varies across markets and system types.; citation_author=Machta RM; citation_author=D Reschovsky J; citation_author=Jones DJ; citation_author=Kimmey L; citation_author=Furukawa MF; citation_author=Rich EC; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=Suppl 3; citation_pages=1062-1072; " /><meta name="citation_reference" content="citation_title=Landscape of health systems in the United States.; citation_author=Furukawa MF; citation_author=Machta RM; citation_author=Barrett KA; citation_journal_title=Med Care Res Rev; citation_year=2020; citation_volume=77; citation_issue=4; citation_pages=357-366; " /><meta name="citation_reference" content="citation_title=Geographic variation in the consolidation of physicians into health systems, 2016-18.; citation_author=Kimmey L; citation_author=Furukawa MF; citation_author=Jones DJ; citation_author=Machta RM; citation_author=Guo J; citation_author=Rich EC; citation_journal_title=Health Aff (Millwood); citation_year=2021; citation_volume=40; citation_issue=1; citation_pages=165-169; " /><meta name="citation_reference" content="citation_title=The price ain’t right? hospital prices and health spending on the privately insured.; citation_author=Cooper Z; citation_author=Craig SV; citation_author=Gaynor M; citation_author=Van Reenen J; citation_journal_title=Q J Econ; citation_year=2019; citation_volume=134; citation_issue=1; citation_pages=51-107; " /><meta name="citation_reference" content="citation_title=The effect of physician and health plan market concentration on prices in commercial health insurance markets.; citation_author=Schneider JE; citation_author=Li P; citation_author=Klepser DG; citation_author=Peterson NA; citation_author=Brown TT; citation_author=Scheffler RM; citation_journal_title=Int J Health Care Finance Econ; citation_year=2008; citation_volume=8; citation_issue=1; citation_pages=13-26; " /><meta name="citation_reference" content="citation_title=Concentration in orthopedic markets was associated with a 7 percent increase in physician fees for total knee replacements.; citation_author=Sun E; citation_author=Baker LC; citation_journal_title=Health Aff (Millwood); citation_year=2015; citation_volume=34; citation_issue=6; citation_pages=916-921; " /><meta name="citation_reference" content="Agency for Healthcare Research and Quality. Compendium of US health systems. Accessed June 1, 2022. https://www.ahrq.gov/chsp/data-resources/compendium.html " /><meta name="citation_reference" content="citation_title=Medical group structural integration may not ensure that care is integrated, from the patient’s perspective.; citation_author=Kerrissey MJ; citation_author=Clark JR; citation_author=Friedberg MW; citation_journal_title=Health Aff (Millwood); citation_year=2017; citation_volume=36; citation_issue=5; citation_pages=885-892; " /><meta name="citation_reference" content="citation_title=Soft consolidation in Medicare ACOs: potential for higher prices without mergers or acquisitions.; citation_author=Lyu PF; citation_author=Chernew ME; citation_author=McWilliams JM; citation_journal_title=Health Aff (Millwood); citation_year=2021; citation_volume=40; citation_issue=6; citation_pages=979-988; " /><meta name="citation_reference" content="citation_title=Medicare accountable care organizations of diverse structures achieve comparable quality and cost performance.; citation_author=Comfort LN; citation_author=Shortell SM; citation_author=Rodriguez HP; citation_author=Colla CH; citation_journal_title=Health Serv Res; citation_year=2018; citation_volume=53; citation_issue=4; citation_pages=2303-2323; " /><meta name="citation_reference" content="citation_title=Consolidation by any other name? the emergence of clinically integrated networks.; citation_author=Ridgely MS; citation_author=Timbie J; citation_author=Duffy E; citation_author=Wolf L; citation_author=Buttorff C; citation_journal_title=Health Serv Res; citation_year=2020; citation_volume=55; citation_issue=S1; citation_pages=114-14; " /><meta name="citation_pdf_url" content="https://jamanetwork.com/journals/jama/articlepdf/2800656/jama_beaulieu_2023_sc_220008_1674242688.01062.pdf" /> <meta name="citation_xml_url" content="https://datafeed.jamanetwork.com/journals/jama/xml/2800656" /> <title>Organization and Performance of US Health Systems | Health Care Reform | JAMA | JAMA Network</title> <meta name="description" content="This Special Communication examines health systems in the United States, assesses differences between physicians and hospitals in and outside of health"> <link rel="canonical" href="https://jamanetwork.com/journals/jama/fullarticle/2800656" /> <script src="//cdn.jamanetwork.com/UI/app/dist/head.min.js?v=638677764511843155"></script> <script src="https://r451.jamanetwork.com/script.js" defer></script> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_HeaderScript"> <meta class="SCM-SharedWidgets-AsyncHeaderAdLoader" data-url="/AMA/AdTag/AMA_AdTag_HeaderScript" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":0,"adSection":"abstract","adPosition":"","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"> </div> </head> <body data-sitename="jama" class="pg_abstract " data-thm="jama"> <script> var App = App || {}; App.suppressAds = App.suppressAds || !!document.getElementsByClassName('suppress-ads').length; App.suppressGtm = App.suppressGtm || !!document.getElementsByClassName('suppress-gtm').length; </script> <div id="ad-interstitial" class="ad-interstitial"> <script defer> googletag.cmd.push(function() { if (App.suppressAds) { return; } // Define a web interstitial ad slot. let interstitialSlot = googletag.defineOutOfPageSlot( App.Ads.adPath + '/abstract', googletag.enums.OutOfPageFormat.INTERSTITIAL, ); if (interstitialSlot) { App.Ads.slots[13] = interstitialSlot; // Enable optional interstitial triggers and register the slot. interstitialSlot .setTargeting('pos', ['interstitial']) .addService(googletag.pubads()) .setConfig({ interstitial: { triggers: { navBar: true, unhideWindow: true, }, }, }); googletag.display(interstitialSlot); googletag.pubads().refresh([interstitialSlot], { changeCorrelator: false }); googletag.enableServices(); } }); </script> </div> <a class="accessible js-skip-to-navigation" href="#skip-to-navigation">[Skip to Navigation]</a> <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-WNKSNP" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript><script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-WNKSNP');</script> <span class="hide tagmanagervalue" data-attribute="productName" data-value="JAMA" data-type="string"></span> <form method="post" action="./2800656" id="webform" class="m0"> <div class="aspNetHidden"> <input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE" value="u6pGJbPR3UVRGBniIBiYEUeM3zBu4AQxdkwsmE6YCttK235P+jpReSowjHUY5rWtRxP71IHEhZmHtXvYcr+q92AvpaM=" /> </div> <div class="aspNetHidden"> <input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="2FAFABAE" /> <input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION" value="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" /> </div> <input id="hdnSiteID" type="hidden" value="3" /> <input id="hdnDomain" type="hidden" value=".jamanetwork.com" /> <section class="master-header"> <script type='text/javascript'> var App = App || {}; App.LoginUserInfo = { isInstLoggedIn: [0], currentSessionId: '01jzeqtk4thuxhkp2mgacuyj' }; </script> <input name="ctl00$ctl00$BodyContent$Header$hfGlobalSearchSiteURL" type="hidden" id="hfGlobalSearchSiteURL" value="https://jamanetwork.com/" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsPaidUser" type="hidden" id="hfAppIsPaidUser" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsMember" type="hidden" id="hfAppIsMember" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppSubscribedTo" type="hidden" id="hfAppSubscribedTo" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsIndividual" type="hidden" id="hfAppIsIndividual" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppHasAccess" type="hidden" id="hfAppHasAccess" value="false" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsReferredFromGoogle" type="hidden" id="hfAppIsReferredFromGoogle" value="False" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrAutoSuggestMinimumCharactersLength" type="hidden" id="hfSolrAutoSuggestMinimumCharactersLength" value="2" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrJournalName" type="hidden" id="hfSolrJournalName" value="JAMA" /> <input name="ctl00$ctl00$BodyContent$Header$hfSolrJournalID" type="hidden" id="hfSolrJournalID" value="J67" /> <input name="ctl00$ctl00$BodyContent$Header$hfAppIsLucy" type="hidden" id="hfAppIsLucy" value="false" /> <div class="header-wrap"> <header class="header"> <div class="widget-GdprCookieBanner widget-instance-GdprCookieBanner"> <div class="gdpr-cookie-wrapper js-gdpr-banner"> <div class="gdpr-cookie-body"> Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our <a href="https://jamanetwork.com/pages/privacy-policy#cookies">Cookie Policy</a> <span class="pipe">|</span> <a href="javascript:;" class="js-gdpr-cookie-acceptLink at-acceptgdpr">Continue</a> </div> <input id="hdnDomain" type="hidden" value=".jamanetwork.com" /> <input id="hdnDomainGdpr" type="hidden" value=".jamanetwork.com" /> <input id="hdnClientIdGdpr" type="hidden" value="3" /> </div> </div> <div class="network-bar"> <a class="jama-network" href="/" title="JAMA Network Home"> <img alt="JAMA Network Home" class="title-image" width="443" height="52" src="//cdn.jamanetwork.com/UI/app/svg/Jama_Network_Logo.svg"> </a> </div> <a class="nav-toggler" href="#nav"> <div class="nav-toggler-indicator"> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> <span class="indicator-stroke"></span> </div> <div class="nav-toggler-site"> <span id="BodyContent_Header_siteFullNamenav" class="nav-toggler-microsite"><span class='network'>JAMA</span></span> </div> </a> <nav id="nav" class="nav hide" > <div class="nav-journal-level sb-nav-journal-level"> <a href="https://jamanetwork.com/journals/jama" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_0" class="home">Home</a><a href="https://jamanetwork.com/journals/jama/newonline" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_1" class="new-online">New Online</a><a href="https://jamanetwork.com/journals/jama/currentissue" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_2" class="current-issue">Current Issue</a><a href="https://jamanetwork.com/journals/jama/pages/for-authors" id="BodyContent_Header_rptMicrositeHeaders_aItemResourceList_3" class="for-authors">For Authors</a> </div> <div class="nav-journals"> <div class="widget-SelfServeContent widget-instance-HamburgerPublicationMenu"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="HamburgerPublicationMenu" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .nav-journals {margin-bottom: 1em;} .nav-heading {color: #B9B9B9;border-bottom: 0;border-top: 1px solid #242424;font-size: 1.15em;font-weight: 400;margin: 0;padding: .7em .75em .25em;text-transform: uppercase;} a.no-bullet:before {content:none !important;} .nav-heading {font-size: 1.15em;margin-bottom:0;padding-left: 38px;} /* .nav-journals a.theme-jama {background-color: #242424;border-bottom: 1px solid #fff;border-top: 1px solid #fff;color: #fff;font-size: 1.15em;margin-bottom: 8px;padding: 11px 0 9px 37px;} .nav-journals a.theme-jama::before {background: unset;content: "\e91b";display: none;font-family: ama_icons !important;font-size: 1.25em;line-height: 1;} .nav-journals a.theme-jama-network-open {border-bottom:0;} */ .nav .widget-instance-HamburgerPublicationMenu a {padding-left: 36px;} .fake-ribbon {border-left: 8px solid #BE1E32;} .fake-ribbon a:before {content:none;} .nav .widget-instance-HamburgerPublicationMenu .fake-ribbon a {padding-left:30px;} .nav-journals a.theme-plus:before {background:#d71635;} .nav-journals a.theme-jama-network-open {border-bottom:0;} </style> <h2 class="nav-heading">JAMA+</h2> <a href="/channels/ai" class="theme-plus">AI</a> <h2 class="nav-heading">Journals</h2> <a href="/journals/jama" class="theme-jama">JAMA</a> <a href="/journals/jamanetworkopen" class="theme-jama-network-open">JAMA Network Open</a> <a href="/journals/jamacardiology" class="theme-jama-cardiology">JAMA Cardiology</a> <a href="/journals/jamadermatology" class="theme-jama-dermatology">JAMA Dermatology</a> <a href="/journals/jama-health-forum" class="theme-jama-health-forum">JAMA Health Forum</a> <a href="/journals/jamainternalmedicine" class="theme-jama-internal-medicine">JAMA Internal Medicine</a> <a href="/journals/jamaneurology" class="theme-jama-neurology">JAMA Neurology</a> <a href="/journals/jamaoncology" class="theme-jama-oncology">JAMA Oncology</a> <a href="/journals/jamaophthalmology" class="theme-jama-ophthalmology">JAMA Ophthalmology </a> <a href="/journals/jamaotolaryngology" class="theme-jama-otolaryngology-head-neck-surgery">JAMA Otolaryngology–Head & Neck Surgery</a> <a href="/journals/jamapediatrics" class="theme-jama-pediatrics">JAMA Pediatrics</a> <a href="/journals/jamapsychiatry" class="theme-jama-psychiatry">JAMA Psychiatry</a> <a href="/journals/jamasurgery" class="theme-jama-surgery">JAMA Surgery</a> <a href="/journals/archneurpsyc" class="theme-archives-of-neurology-psychiatry-1919-1959-">Archives of Neurology & Psychiatry (1919-1959)</a> <h2 class="nav-heading">Podcasts</h2> <a href="/journals/jama/pages/jama-clinical-reviews">Clinical Reviews</a> <a href="/journals/jama/pages/jama-editors-summary">Editors' Summary</a> <a href="/journals/jama/pages/jama-medical-news">Medical News</a> <a href="/journals/jama/pages/jama-author-interviews">Author Interviews</a> <a href="/pages/audio" class="no-bullet">More</a> </div> </div> </div> <div class="nav-network-other"> <a href="https://edhub.ama-assn.org/jn-learning" id="BodyContent_Header_rptOtherResources_aItemResourceList_0" class="is-b link-jn-learning-cme" target="_blank">JN Learning / CME</a><a href="https://store.jamanetwork.com/index.aspx?productcode=64" id="BodyContent_Header_rptOtherResources_aItemResourceList_1" class="is-b link-subscribe" target="_blank">Subscribe</a><a href="https://careers.jamanetwork.com/" id="BodyContent_Header_rptOtherResources_aItemResourceList_2" class="is-b link-jobs" target="_blank">Jobs</a><a href="https://jamanetwork.com/pages/resources-for-librarians" id="BodyContent_Header_rptOtherResources_aItemResourceList_3" class="is-b link-institutions-librarians">Institutions / Librarians</a><a href="https://jamanetwork.com/pages/reprints-and-permissions" id="BodyContent_Header_rptOtherResources_aItemResourceList_4" class="is-b link-reprints-permissions" rel="nofollow">Reprints & Permissions</a> </div> <div class="white text-xxs"> <div class="p05 ml4 mr3 mb1 mt10 flex hamburger-menu-legal"> <a href="/pages/conditions-of-use" class="p0" rel="nofollow">Terms of Use</a> <span class="pl1 pr1">| </span> <a href="/pages/privacy-policy" class="p0" rel="nofollow">Privacy Policy</a> <span class="pl1 pr1">| </span> <a href="/pages/accessibility-statement" class="p0" rel="nofollow">Accessibility Statement</a> </div> <div class="ta-c"> <span class="pb1">2024 American Medical Association. All Rights Reserved</span> </div> </div> </nav> <a class="toolbar-search-trigger is-b" data-mobile-tog-target=".site-search"></a> <div id="site-search" role="search" class="site-search"> <div class="site-search-bar"> <div role="search"> <select name="ctl00$ctl00$BodyContent$Header$ddlForSearch" id="BodyContent_Header_ddlForSearch" Name="dropDownList" class="cs-select cs-skin-border" title="Search Site Selector" role="options" aria-labelledby="searchLabel"> <option value="J*">Search All</option> <option value="3">JAMA</option> <option value="214">JAMA Network Open</option> <option value="192">JAMA Cardiology</option> <option value="12">JAMA Dermatology</option> <option value="261">JAMA Forum Archive</option> <option value="193">JAMA Health Forum</option> <option value="15">JAMA Internal Medicine</option> <option value="16">JAMA Neurology</option> <option value="159">JAMA Oncology</option> <option value="17">JAMA Ophthalmology</option> <option value="18">JAMA Otolaryngology–Head & Neck Surgery</option> <option value="19">JAMA Pediatrics</option> <option value="14">JAMA Psychiatry</option> <option value="20">JAMA Surgery</option> <option value="23">Archives of Neurology & Psychiatry</option> </select> </div> <div class="search-input-container"> <input type="search" name="textbox" autocomplete="off" role="textbox" id="search-term" aria-labelledby="searchLabel" class="search-term at-microsite-search-term" placeholder="Enter Search Term" maxlength="255" title="Enter Search Term"> <ul id="umbrellaSiteAutoCompleteResults" class="term-list hidden"></ul> <label style="display:none" for="umbrellaSiteSearchInputHint" id="searchLabel">Input Search Term</label> <input class="searchTerm search-input" name="textbox" role="textbox" type="text" id="umbrellaSiteSearchInputHint" aria-labelledby="searchLabel" title="Input Search Term" autocomplete="off"> </div>  <a name="button" role="button" class="search-button is-b js-search-button" alt="search button" href="/searchresults"></a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_auth" class="auth"> <a class="auth--trigger is-b is-a" href="javascript:;"> <span id="BodyContent_Header_GlobalSignIn_spnUserFullName" class="user-full-name">Sign In</span> </a> <div class="auth--dropdown js-signIn-dropdown"> <div class="auth--option auth--ind"> <div id="BodyContent_Header_GlobalSignIn_divUserFullName" class="auth--ind-user"></div> <div id="BodyContent_Header_GlobalSignIn_divIndSignIn" class="auth--ind-auth"> <div class="auth--title">Individual Sign In</div> <a href="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656" id="BodyContent_Header_GlobalSignIn_oauthSignInLink" rel="nofollow" class="auth--ind-sign-in">Sign in</a><a href="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656" id="BodyContent_Header_GlobalSignIn_oauthSignUpLink" rel="nofollow" class="auth--ind-create">Create an Account</a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_divInstSignIn" class="auth--option auth--inst"> <div class="auth--inst-auth"> <div class="auth--title">Access through your institution</div> <a href="/signinshibboleth?returnUrl=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656" id="BodyContent_Header_GlobalSignIn_institutionSignIn" rel="nofollow" class="auth--shib">Sign In</a> </div> </div> <div id="BodyContent_Header_GlobalSignIn_divPurchaseOptions" class="auth--option auth--purchase"> <div class="auth--title">Purchase Options:</div> <a id="BodyContent_Header_GlobalSignIn_lnkBuyArticle" class="auth--buy" href="https://jamanetwork.com/oauthsignin?return_url=https://store.jamanetwork.com/CustomerType.aspx?articleId=2800656">Buy this article</a> <div class="widget-DeepDyve widget-instance-AMAv2_DeepDyve"> <a rel="nofollow" data-doi="10.1001/jama.2022.24032" data-fieldname="journal_doi" data-issneissn="0098-7484" data-affiliate="JAMA" class="deepDiveLink auth--shib deep-dive-wrap js-deepdyve-link" href="https://www.deepdyve.com/doc-view?docId=10.1001/jama.2022.24032&fieldName=journal_doi&affiliateId=JAMA" target="_blank">Rent this article</a> </div> <a id="BodyContent_Header_GlobalSignIn_lnkSubscribeJournal" class="auth--subscribe" rel="nofollow" href="https://store.jamanetwork.com/index.aspx?productcode=64">Subscribe to the JAMA journal</a> </div> </div> </div> </header> </div> <div class="editors-choice-header"> </div> <div id="BodyContent_Header_divAds" class="header-ad-wrap sb-background-primary-dark"> <div class="leader-ad desktop-only"> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_LeaderboardAd"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_LeaderboardAd" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":1,"adSection":"abstract","adPosition":"atf","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> </div>  </section> <section class="master-main"> <span class="hide tagmanagervalue" data-attribute="template" data-value="abstract" data-type="string"></span> <script type="application/ld+json"> { "@context": "https://schema.org/", "@type": "Article", "headline": "Organization and Performance of US Health Systems", "author": "Nancy D. Beaulieu, PhD", "url": "https://jamanetwork.com/journals/jama/fullarticle/2800656", "datePublished": "2023-01-24", "description": "This Special Communication examines health systems in the United States, assesses differences between physicians and hospitals in and outside of health systems, and compares quality and cost of care delivered by physicians and hospitals in and outside of health systems.", "publisher": { "@type": "Organization", "name": "JAMA Network", "logo": { "@type": "ImageObject", "url": "//cdn.jamanetwork.com/UI/app/img/favicons/jama/favicon.ico" } }, "image": [ "https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008f1_1674242688.25598.png?Expires=2147483647&Signature=DT~fjXkwSC~Im~bpHRVsSLWfV0RryCpIcFXvpiqVMl6-3XweNHbQmOanoJvmVMxUVIAvs9xNo4t8w7iPkNQhqwjsVI9Ds5WgD4dhL8H6FbARHO51JFMtu6M~5vo0RQatUH3KknmSO~MUQay3gkswWc7KJrK2ZdSLp8BfYRwEh~9SuXmJfLdwnslKlxbR11DpLKN5Jahmt8JLUQq~ksK-w4nk1HCsto039PHTwpMLzaYiY8z-okBaN4yKmU2AugecbJoRgWi0fphk83aEyD~vUQ8LuEavsH1YeCCW-fUxEmpsrSevG8qFQq2MR0j2DmzrvSWGSk-MKFRAo8FW9lYWhA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008f2_1674242688.28096.png?Expires=2147483647&Signature=3bdli5Bd1iDrOw5njjH1LmWLPvaScxdOMzW-icpacNyfz08cJU9ohpD3wUZh6EDCaw1FbwVOpkEjdxofpmr53rXilbxzSzwa8m0D4C7W0gA2nUF0-K9JccDLF-iIoNH1LenK~s8TFm1MMvCACq0-JTUeShNN8Hu1epVnvNboJDjatOAGFYP-dl6~L5Nly8LrFTWJIdozfzEETm4WdH-PrU1sFyHOL8pXD2xRYFRzKoAct1uFNsi-arDGbUbsdaH4dXNeg~oEXErFNwVpDpJnCQHcdjPu20U3wi6I4hIGCnWT2PR4p1ZHZnPl7rQbUKcihXW9u3guYYKjUs29Hgv9Yw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t1_1674242688.30092.png?Expires=2147483647&Signature=FNHRxTIxdUV1aq~04wUwgHu9MFBpF9qBuen5cuz~4glnRdm8s~QcaMrWnEZWhntzJdXRyI3GJ-6sP75-BsyNoaw1AZLCZ~aScic3RLWCApERG~ofOoI1IoteBymStVSDSSoHcOvr2BZC8QolGbpdLM883mObPrIrKoTj8ibyEUbOiC-xqe1NXoUyuP1xa2uoYxOxgqoa6IrL7OERq1oTAuqy0lWByEfNItxDmhFNR1yGXxItqSfXPDg3m7Wq2RERFr7hZzB4e2wcOZoFs6P~TcHZFjQr4Q2WTDI9tcu1Jn3WZRGb56SsIyK5bc-qYqi00nM02YBdXyPbhMLK3VRoww__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t2_1674242688.36097.png?Expires=2147483647&Signature=v8hFJ5oZIY6BfyUsiNagcV-fRds~KC3grJJ1Y9of-zra7psx-1JPh0KXjEvQABudlUq43Ei8ZpX1YqCXTvKfeqtlbMOFqwzQmHHvye-w~QHv8sU0CWElJzvjAq5tKSHXEjYAVP5c5Aqs~qKaCAZI2Sltf7VskMX8Do6v7abwZx9hbSxN954lDeHXliQj~raAunoL2A3R9J0qiPcCu-F4XuWKo~1Vl9leG2MtZVtUo~0STOULgK416c0JcClWO6PSzX45cK77cgGhDAjpu5Z63Jq-eyJd3QwGRPZTUqicPqiPxUtLBTLw1PBZVZIAjdu91hK85CxF0b1TLypuWQ6CCg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA", "https://cdn.jamanetwork.com/ama/content_public/journal/jama/939073/jsc220008t3_1674242688.39094.png?Expires=2147483647&Signature=aq-b3As1SMayNDnaxAWf2xymtYTajIPeI6aCAcNS~R-GrhUC2fyygjMzxqWVC6ATn~wRBo3XeMT6unoWrqbaMd1msCO1xAl2C0R68Hns74vFqViDzPUROSCKmleyGbWlXqDR~rNpBNlQfHIfparOtjG060xIgwXhFKu4D-0Z8ghmEOZd6584ECsmrImNcXL-mZ6~vFO-IjrXORFKY8AS8DratqGZIkAz6uoq9fHz505nplkAh8VWE7UStKDN8~N-0u5ymYNrDXtgMSu62PYm4WWAflaXeoCBxvJDtPgLGuR0THE5huyzka5tJsyru9oBSC8m3M~UCllyihVvQBZNCQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" ], "articleSection": [ "Introduction", "Methods", "Health System Definition and Description", "Performance Measures", "Quality and Utilization", "Commercial Prices", "Patient Characteristics", "Percentage of Care Delivered in Systems", "Statistical Analysis", "Results", "Description of Health Systems", "Comparison of Hospitals and Physicians In and Out of Health Systems", "Physicians and Practices in and out of Health Systems", "Proportion of Care Delivered by Health System Physicians and Hospitals", "Comparative Performance of Health Systems", "Characteristics of Medicare Beneficiaries", "Clinical Quality", "Low-Value Care Utilization", "Patient Experiences", "Commercial Prices", "Spending", "Performance and Price Differences Associated With Physician Practice Size", "Summary", "Discussion", "Limitations", "Conclusions", "Article Information", "References" ], "keyWords": "health care systems, medicare" } </script> <div class="widget-UserContentAccessWrite widget-instance-AMA_UserContentAccessWrite_AbstractView"> <div class="SCM-SharedWidgets-LocalStorage-UserContentAccessWrite" data-values='{"id":"2800656","type":"Article","date":"11/27/2024 10:05:32 PM"}'></div> </div> <a id="skip-to-navigation" href="#" tabindex="-1"></a> <div class="ymal--leader hide-small"> <div id="BodyContent_PageContent_ymalPersonalized" class="ymal--personalized js-ymal-personalized hide"> <div class="widget-WidgetLoader widget-instance-AMA_PersonalizedContent_AbstractView_Leaderboard"> <div class="SCM-SharedWidgets-AsyncWidgetLoader" data-url="/Personalization/PersonalizedContent/AMA_PersonalizedContent_AbstractView_Leaderboard" data-params="{"parameters":{"resourceIdToExclude":2800656,"resourceTypeToExclude":3},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div id="BodyContent_PageContent_ymalCurated" class="ymal--curated js-ymal-curated"> <div class="ymal row"> </div> </div> </div> <div class="content pb0"> <a id="top"></a> <div class="article-content"> <div class="social-share hide" data-share-journal="JAMA_current" data-share-title="Organization and Performance of US Health Systems"> <a class="st-custom-button addthis_button_twitter is-b toolbar-twitter toolbar-share" data-network="twitter" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">X</span> </a> <a class="st-custom-button addthis_button_facebook is-b toolbar-facebook toolbar-share" data-network="facebook" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">Facebook</span> </a> <div class="toolbar-share-more"> <a class="st-custom-button addthis_button_linkedin is-b toolbar-linkedin toolbar-share" data-network="linkedin" data-title="" data-url="" data-email-subject="" rel="nofollow" href="javascript:;"> <span class="share-text">LinkedIn</span> </a> </div> <a class="toolbar-share-more-link is-a" rel="nofollow" data-tog-target=".social-share .toolbar-share-more"><span class="icon icon-carrot_down social-arrow"></span>More</a> </div> <div class="widget-ArticleLinks widget-instance-AMA_ErrataArticleLinks_Abstract"> </div> <div class="widget-ArticleLinks widget-instance-AMA_ArticleLinks_ToErrata_Abstract"> </div> <div class="widget-ArticleNavLinks widget-instance-AMA_ArticleNavLinks_Abstract"> <a class="toc-link btn" href="https://jamanetwork.com/journals/jama/issue/329/4">This Issue</a> </div> <div id="BodyContent_PageContent_divArticleLevelMetrics" class="article-metrics-wrapper"> <div class="widget-ArticleLevelMetrics widget-instance-AMA_ArticleMetrics"> <div class="artmet-condensed-wrap clearfix"> <div class="artmet-condensed-stats clearfix"> <div class="artmet-item artmet-views"> <span class="artmet-text sb-sc">Views</span> <span class="artmet-number sb-sc">14,022</span> </div> <div class="artmet-item artmet-citations"> <a class="artmet-citations-link" href="https://www.webofscience.com/api/gateway?GWVersion=2&SrcApp=silverchair&SrcAuth=WosAPI&KeyUT=WOS:000987382900021&DestLinkType=FullRecord&DestApp=WOS_CPL" target="_blank"> <span class="artmet-text">Citations</span> <span class="artmet-number">22</span> </a> </div> <div class="artmet-item artmet-altmetric"> <div class="widget-AltmetricLink widget-instance-AMAv2_ArticleLevelMetrics_AltmetricLinkSummary">  <div id="altmetricEmbedId" class='altmetric-embed' data-link-target="_blank" data-badge-type="text" data-hide-no-mentions="false" data-doi="10.1001/jama.2022.24032" ></div> </div> </div> </div> <div class="artmet-modal-trigger-wrap"> <a rel="nofollow" class="artmet-modal-trigger" data-article-id="2800656"><i class="icon-metrics"></i><span>View Metrics</span></a> </div> </div> </div> </div> <ul class="toolbar-trigger"> <li class="toolbar-pdf-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-pdf is-b" data-trigger=".abstract-toolbar .toolbar-pdf"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span></a> </li> <li class="toolbar-full-text-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-full-text is-b" data-url="" data-article-id="2800656" data-trigger=".abstract-toolbar .toolbar-full-text">Full Text</a> </li> <li class="toolbar-cme-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-cme is-b jama-active-cme-button" data-trigger=".abstract-toolbar .toolbar-cme" rel="nofollow">CME & MOC</a> </li> <li class="toolbar-share-wrap toolbar-tool-wrap"> <div class="toolbar-tool toolbar-share is-b"> <a class="toolbar-share-more-link">Share</a> <div class="toolbar-share-more"> <a class="toolbar-share toolbar-twitter is-b" rel="nofollow" data-trigger=".social-share .toolbar-twitter"><span class="share-text">X</span></a> <a class="toolbar-share toolbar-facebook is-b" rel="nofollow" data-trigger=".social-share .toolbar-facebook"><span class="share-text">Facebook</span></a> <a class="toolbar-share toolbar-email is-b" rel="nofollow" data-trigger=".social-share .toolbar-email"><span class="share-text">Email</span></a> <a class="toolbar-share toolbar-linkedin is-b" rel="nofollow" data-trigger=".social-share .toolbar-linkedin"><span class="share-text">LinkedIn</span></a> </div> </div> </li> <li class="toolbar-citation-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-citation is-b stats-citation" rel="nofollow" data-trigger=".abstract-toolbar .toolbar-citation"><span class="toolbar-link-text">Cite</span> <span class="toolbar-link-text-extra">This</span></a> </li> <li class="toolbar-permissions-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-permissions is-b" rel="nofollow" data-trigger=".abstract-toolbar .toolbar-permissions"><span class="toolbar-link-text">Permissions</span></a> </li> </ul> <div class="widget-ArticleTopInfo widget-instance-AMA_ArticleTop_Info_Widget"> <span class="hide tagmanagervalue" data-attribute="articleId" data-value="2800656" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="arrArticleAuthor" data-value="Nancy%20D.%C2%A0Beaulieu%2C%C2%A0PhD,Michael%20E.%C2%A0Chernew%2C%C2%A0PhD,J.%20Michael%C2%A0McWilliams%2C%C2%A0MD%2C%20PhD,Mary%20Beth%C2%A0Landrum%2C%C2%A0PhD,Maurice%C2%A0Dalton%2C%C2%A0MA,Angela%20Yutong%C2%A0Gu%2C%C2%A0MA,Michael%C2%A0Briskin%2C%C2%A0BA,Rachel%C2%A0Wu%2C%C2%A0BA,Zakaria%C2%A0El%20Amrani%20El%20Idrissi%2C%C2%A0BA,Helene%C2%A0Machado%2C%C2%A0BS,Andrew%20L.%C2%A0Hicks%2C%C2%A0MA,David%20M.%C2%A0Cutler%2C%C2%A0PhD" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="articleDOI" data-value="10.1001/jama.2022.24032" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articleTitle" data-value="Organization and Performance of US Health Systems" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="type" data-value="Special Communication" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="issueVolume" data-value="329" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="issueNo" data-value="4" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="publishDate" data-value="January 24, 2023" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="topics" data-value="Health Care Reform, Health Care Economics, Insurance, Payment, Health Policy, Health Care Quality" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="topicCode" data-value="5680, 42114, 44020, 42116" data-type="array"></span> <span class="hide tagmanagervalue" data-attribute="category" data-value="Review" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="journalClub" data-value="No" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentStatus" data-value="Locked" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="articlePubState" data-value="Final" data-type="string"></span> <span class="hide tagmanagervalue" data-attribute="contentMedium" data-value="Article" data-type="string"></span> <div class="meta-article-type-wrap"> <div class="meta-article-type thm-col">Special Communication </div> </div> <div class="meta-date"><span class="ppub"><span class="month">January </span><span class="day">24/31, </span><span class="year">2023</span></span></div> <div class="meta-article-title-wrap"> <h1 class="meta-article-title ">Organization and Performance of US Health Systems</h1> </div> <div class="meta-authors"> <span class="meta-authors--limited"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Nancy+D.+Beaulieu&q=Nancy+D.+Beaulieu" rel=nofollow target="_blank">Nancy D. Beaulieu, PhD<sup>1</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Michael+E.+Chernew&q=Michael+E.+Chernew" rel=nofollow target="_blank">Michael E. Chernew, PhD<sup>1,2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=J.+Michael+McWilliams&q=J.+Michael+McWilliams" rel=nofollow target="_blank">J. Michael McWilliams, MD, PhD<sup>1,3</sup></a></span>; <a class="meta-authors--etal td-u stats-meta-authors--etal">et al</a></span> <span class="meta-authors--remaining"><span class="wi-fullname brand-fg"><a href="/searchresults?author=Mary+Beth+Landrum&q=Mary+Beth+Landrum" rel=nofollow target="_blank">Mary Beth Landrum, PhD<sup>1</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Maurice+Dalton&q=Maurice+Dalton" rel=nofollow target="_blank">Maurice Dalton, MA<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Angela+Yutong+Gu&q=Angela+Yutong+Gu" rel=nofollow target="_blank">Angela Yutong Gu, MA<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Michael+Briskin&q=Michael+Briskin" rel=nofollow target="_blank">Michael Briskin, BA<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Rachel+Wu&q=Rachel+Wu" rel=nofollow target="_blank">Rachel Wu, BA<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Zakaria+El+Amrani+El+Idrissi&q=Zakaria+El+Amrani+El+Idrissi" rel=nofollow target="_blank">Zakaria El Amrani El Idrissi, BA<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Helene+Machado&q=Helene+Machado" rel=nofollow target="_blank">Helene Machado, BS<sup>2</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=Andrew+L.+Hicks&q=Andrew+L.+Hicks" rel=nofollow target="_blank">Andrew L. Hicks, MA<sup>1</sup></a></span><span class='al-author-delim'>; </span><span class="wi-fullname brand-fg"><a href="/searchresults?author=David+M.+Cutler&q=David+M.+Cutler" rel=nofollow target="_blank">David M. Cutler, PhD<sup>2,4</sup></a></span></span> </div> <div class="meta-author"> <a class="meta-author-title is-b stats-meta-author-toggle" data-tog-target=".meta-author-content">Author Affiliations</a> <a class="meta-articleinfo-jumplink section-jump-link scroll-to stats-scroll-to-articleinfo" data-tab-toggle=".tab-nav-full-text" href="#248807445">Article Information</a> <div class="meta-author-content"> <ul class="meta-author-affiliations"> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>1</sup>Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>2</sup>National Bureau of Economic Research, Cambridge, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>3</sup>Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts</div> </li> <li class="meta-author-affiliation"> <div class="meta-author-name"><sup>4</sup>Department of Economics, Harvard University, Cambridge, Massachusetts</div> </li> </ul> </div> </div> <div class="meta-citation-wrap"> <span class="meta-citation-journal-name">JAMA. </span><span class="meta-citation"> 2023;329(4):325-335. doi:10.1001/jama.2022.24032</span> </div> </div> <div class="widget-EditorsChoice widget-instance-AMA_EditorsChoice_Links"> </div> <div class="widget-LinkedContentToolbar widget-instance-AMA_LinkedContentToolbar"> <div class="linked-content-toolbar"> <div class="hidden js-search-open-multimedia-by-default" showContentByDefault="False"></div> <div class="linked-content-controls"> <a class="linked-content-trigger td-n stats-graphical-abstract" href="#graphical-abstract-tab"> <i class="icon-visual-abstract"><span class="sr-t">visual abstract icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Visual <div>Abstract</div></div> </a> <a class="linked-content-trigger td-n stats-editorial-comment" href="#editorial-comment-tab"> <i class="icon-document"><span class="sr-t">editorial comment icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Editorial <div>Comment</div></div> </a> <a class="linked-content-trigger td-n stats-related-articles" href="#related-articles-tab"> <i class="icon-related"><span class="sr-t">related articles icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Related <div>Articles</div></div> </a> <a class="linked-content-trigger td-n stats-author-interviews" href="#author-interviews-tab"> <i class="icon-author_interview"><span class="sr-t">author interview icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Interviews</div> </a> <a class="linked-content-trigger td-n stats-more-multimedia" href="#more-multimedia-tab"> <i class="icon-multimedia"><span class="sr-t">multimedia icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Multimedia</div> </a> <a class="linked-content-trigger td-n stats-listen-to-this-article" href="#listen-to-this-article-tab"> <i class="icon-audio"><span class="sr-t">audio icon</span></i> <div class="trigger-text d-ib va-m ta-l fw-5">Listen to <div>this article</div></div> </a> </div> <div class="linked-content-tabs"> <div id="graphical-abstract-tab" class="linked-content-tab graphical-abstract-tab"> <div class="widget-SectionDisplay widget-instance-AMA_GraphicalAbstract_Tab"> </div> </div> <div id="editorial-comment-tab" class="linked-content-tab editorial-comment-tab"> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_EditorialComments"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jama/fullarticle/2800683"> <div class="related-article-type">Editorial</div> <div class="related-article-title sb-tc">Health Systems—The Present and the Future</div> </a> <div class="related-article-authors">Lawrence P. Casalino, MD, PhD</div> <div class="related-article-journal-name">JAMA</div> </li> </ul> </div> </div> <div id="related-articles-tab" class="linked-content-tab related-article-tab"> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_RelatedArticle"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jama/fullarticle/1769891"> <div class="related-article-type">Special Communication</div> <div class="related-article-title sb-tc">Hospitals, Market Share, and Consolidation</div> </a> <div class="related-article-authors">David M. Cutler, PhD; Fiona Scott Morton, PhD</div> <div class="related-article-journal-name">JAMA</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jama/fullarticle/2785480"> <div class="related-article-type">Viewpoint</div> <div class="related-article-title sb-tc">Administrative Simplification and the Potential for Saving a Quarter-Trillion Dollars in Health Care</div> </a> <div class="related-article-authors">Nikhil R. Sahni, BA, BAS, BSe, MBA, MPA/ID; Brandon Carrus, BS, MSc; David M. Cutler, AB, PhD</div> <div class="related-article-journal-name">JAMA</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jama/fullarticle/2800652"> <div class="related-article-type">Viewpoint</div> <div class="related-article-title sb-tc">Disentangling the Role of Health Care Systems in Producing High-Quality Care</div> </a> <div class="related-article-authors">Valerie A. Lewis, PhD; Genevra F. Murray, PhD; Darren A. DeWalt, MD, MPH</div> <div class="related-article-journal-name">JAMA</div> </li> <li class="article-link related-abstract-article"> <a class="related-article-title" href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2776022"> <div class="related-article-type">JAMA Forum</div> <div class="related-article-title sb-tc">Building Health Care Better Means Reining in Costs</div> </a> <div class="related-article-authors">David Cutler, PhD</div> <div class="related-article-journal-name">JAMA Health Forum</div> </li> </ul> </div> <div class="widget-ArticleLinks widget-instance-AMA_LinkedContentToolbar_RelatedEditorsChoices"> </div> </div> <div id="author-interviews-tab" class="linked-content-tab linked-author-interviews-tab"> <div class="widget-AudioPlayer widget-instance-AMA_LinkedContentToolbar_PlatformAudioPlayer_AuthorInterviews"> </div> </div> <div id="listen-to-this-article-tab" class="linked-content-tab linked-listen-to-this-article-tab"> <div class="widget-AudioPlayer widget-instance-AMA_LinkedContentToolbar_PlatformAudioPlayer_ListenToThisArticle"> </div> </div> <div id="more-multimedia-tab" class="linked-content-tab more-multimedia-tab"> </div> </div> </div> </div> <a class="full-text-link is-b" data-url="" data-article-id="2800656"> <div class="full-text-link--text"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="abstract-content"> <div class="widget-ArticleFulltext widget-instance-AMA_Article_Abstract_Widget"> <div class="article-full-text" data-userHasAccess="False"> <a class="article-section-id-anchor" id="248807365"></a> <div class="h3 cb section-type-abstract decorated-hed "> <div class="heading-text thm-col sb-sc"> Abstract </div> </div> <p><strong>Importance</strong> <span>Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance.</span></p><p><strong>Objective</strong> <span>To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quality and cost of care delivered by physicians and hospitals in and outside of health systems.</span></p><p><strong>Evidence Review</strong> <span>Health systems were defined as groups of commonly owned or managed entities that included at least 1 general acute care hospital, 10 primary care physicians, and 50 total physicians located within a single hospital referral region. They were identified using Centers for Medicare & Medicaid Services administrative data, Internal Revenue Service filings, Medicare and commercial claims, and other data. Health systems were categorized as academic, public, large for-profit, large nonprofit, or other private systems. Quality of preventive care, chronic disease management, patient experience, low-value care, mortality, hospital readmissions, and spending were assessed for Medicare beneficiaries attributed to system and nonsystem physicians. Prices for physician and hospital services and total spending were assessed in 2018 commercial claims data. Outcomes were adjusted for patient characteristics and geographic area.</span></p><p><strong>Findings</strong> <span>A total of 580 health systems were identified and varied greatly in size. Systems accounted for 40% of physicians and 84% of general acute care hospital beds and delivered primary care to 41% of traditional Medicare beneficiaries. Academic and large nonprofit systems accounted for a majority of system physicians (80%) and system hospital beds (64%). System hospitals were larger than nonsystem hospitals (67% vs 23% with >100 beds), as were system physician practices (74% vs 12% with >100 physicians). Performance on measures of preventive care, clinical quality, and patient experience was modestly higher for health system physicians and hospitals than for nonsystem physicians and hospitals. Prices paid to health system physicians and hospitals were significantly higher than prices paid to nonsystem physicians and hospitals (12%-26% higher for physician services, 31% for hospital services). Adjusting for practice size attenuated health systems differences on quality measures, but price differences for small and medium practices remained large.</span></p><p><strong>Conclusions and Relevance</strong> <span>In 2018, health system physicians and hospitals delivered a large portion of medical services. Performance on clinical quality and patient experience measures was marginally better in systems but spending and prices were substantially higher. This was especially true for small practices. Small quality differentials combined with large price differentials suggests that health systems have not, on average, realized their potential for better care at equal or lower cost.</span></p> <div class="movable-ad-target bta"> </div> </div> </div> <div class="widget-ArticleLinks widget-instance-AMA_Abstract_EditorialComments"> <ul class="article-abstract-links related-abstract-content"> <li class="article-link related-abstract-article"> <a class="related-article-abstract-link" href="https://jamanetwork.com/journals/jama/fullarticle/2800683"> <div class="related-article-abstract-type">Editorial</div> <div class="related-article-abstract-title sb-tc">Health Systems—The Present and the Future</div> </a> <div class="related-article-journal-name">JAMA</div> </li> </ul> </div> <a class="full-text-link is-b d-b bd-none ta-c fl-n radius mt1 mb1 m-auto" data-url="" data-article-id="2800656"> <div class="full-text-link--text fw-b"><span class="full-text-link--text-top">Full </span>Text</div> </a> <div class="seamless-access-button--mobile-only"> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_AdvancedSeamlessAccessButton_Mobile"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> </div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_abstract_bta_dual"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_abstract_bta_dual" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":8,"adSection":"abstract","adPosition":"bta","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="widget-RelatedTopics widget-instance-AMA_Related_Topics_Abstract"> <div class="related-topics-block"> <h4 class="related-topics-heading topic-suggestions-heading sb-sc"> Read More About </h4> <div class="related-topics topic-suggestions"> <a href="https://jamanetwork.com/collections/5680/health-care-reform" id="item_Link" class="related-topic topic-suggestion no-wrap sb-anchor-light">Health Care Reform</a> <a href="https://jamanetwork.com/collections/42114/health-care-economics-insurance-payment" id="item_Link_1" class="related-topic topic-suggestion no-wrap sb-anchor-light">Health Care Economics, Insurance, Payment</a> <a href="https://jamanetwork.com/collections/44020/health-policy" id="item_Link_2" class="related-topic topic-suggestion no-wrap sb-anchor-light">Health Policy</a> <a href="https://jamanetwork.com/collections/42116/health-care-quality" id="item_Link_3" class="related-topic topic-suggestion no-wrap sb-anchor-light">Health Care Quality</a> </div> </div> </div> </div> <div class="sidebar"> <div class="branded-bar"></div> <div class="abstract-toolbar"> <a id="pdf-link" href="/journals/jama/articlepdf/2800656/jama_beaulieu_2023_sc_220008_1674242688.01062.pdf" class="toolbar-tool toolbar-pdf al-link pdfaccess js-pdfaccess" data-article-id="2800656" data-article-url="/journals/jama/articlepdf/2800656/jama_beaulieu_2023_sc_220008_1674242688.01062.pdf" data-ajax-url="/Content/CheckPdfAccess"><span class="toolbar-pdf-text"><span class="toolbar-link-text-extra">Download </span><span class="toolbar-link-text">PDF</span></span> </a> <a class="toolbar-tool toolbar-full-text is-b" data-url="" data-article-id="2800656"><span class="toolbar-link-text-extra">Full</span> Text</a> <div class="widget-ToolboxGetCitation widget-instance-AMA_Get_Citation_Abstract"> <a class="toolbar-tool toolbar-citation is-b stats-citation" rel="nofollow" data-reveal-id="get-citation" data-reveal> <span class="toolbar-link-text">Cite</span> <span class="toolbar-link-text-extra">This</span> </a> <div id="get-citation" class="reveal-modal get-citation" data-reveal> <h3 class="get-citation-title">Citation</h3> <p class="get-citation-citation">Beaulieu ND<span class='al-author-delim'>, </span>Chernew ME<span class='al-author-delim'>, </span>McWilliams JM, et al. Organization and Performance of US Health Systems. <em>JAMA.</em> 2023;329(4):325–335. doi:10.1001/jama.2022.24032</p> <h4 class="get-citation-download-heading">Manage citations:</h4> <div class="get-citation-types"> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=0">Ris (Zotero)</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=1">EndNote</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=2">BibTex</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=3">Medlars</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=0">ProCite</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=3">RefWorks</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=0">Reference Manager</a> <a class="get-citation-format" rel="nofollow" href="/Citation/Download?resourceId=2800656&resourceType=3&citationFormat=0">Mendeley</a> </div> <p class="get-citation-copyright">© 2024 </p> <a class="close-reveal-modal icon-close" rel="nofollow"></a> </div> </div> <div class="widget-ToolboxPermissions widget-instance-AMA_Get_Permissions_Abstract"> <a href="http://s100.copyright.com/AppDispatchServlet?publisherName=AMA&publication=0098-7484&title=Organization+and+Performance+of+US+Health+Systems&publicationDate=2023-01-24&volumeNum=329&issueNum=4&author=Beaulieu%2c+Nancy+D.%3b+Chernew%2c+Michael+E.&startPage=325&endPage=335&contentId=10.1001%2fjama.2022.24032&oa=&orderBeanReset=True" rel="nofollow" id="PermissionsLink" class="toolbar-tool toolbar-permissions is-b" target="_blank"><span class="toolbar-link-text">Permissions</span></a> </div> <li class="toolbar-cme-wrap toolbar-tool-wrap"> <a class="toolbar-tool toolbar-cme is-b jama-active-cme-button" rel="nofollow" href="https://edhub.ama-assn.org/jn-learning/module/2800656">CME & MOC</a> </li> </div> <div class="seamless-access-button--desktop-only"> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_AdvancedSeamlessAccessButton_Desktop"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> </div> <div class="widget-SignUpAffinityAlert widget-instance-AMAv2_AffinityAlertSignUp"> </div> <div class="cme-promo ta-c"> <div class="widget-SelfServeContent widget-instance-AMA_SelfServe_Promote_Cme_To_Inst_SubUsers"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="AMAV2_Rightrail_Other_Promo" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="bc_rr_theme_promo"></div> <div class="bc_right_rail_article_promo"></div> <link rel="stylesheet" href="https://cdn.jamanetwork.com/data/CSSUploads/jamanetwork-selfserve-maintenance.css?versionId=82944"> <style type="text/css"> .jn-rr-feature {border-top: 4px solid #d71635; border-bottom: 4px solid #d71635;} p.globe-icon {font-weight:700;padding:0.35em 0} .icon-url:before {font-size:24px;margin-right:6px;} .icon-url:hover {text-decoration: none;} </style> <div class="jn-rr-feature"> <p class="globe-icon"><a href="/channels/ai" target="_blank"><span class="badge icon-url"></span>JAMA+ AI</a></p> </div>  <div class="bc_maintenance"></div> <iframe id="selfserve-maintenance" src="https://sites.jamanetwork.com/maintenance/index.html" width="100%" frameborder="0"></iframe>  </div> </div> </div> <div class="widget-WidgetLoader widget-instance-AMA_PersonalizedContent_AbstractView_RightRail"> <div class="SCM-SharedWidgets-AsyncWidgetLoader" data-url="/AMA/PersonalizedContent_RightRail/AMA_PersonalizedContent_AbstractView_RightRail" data-params="{"parameters":{"resourceIdToExclude":2800656,"resourceTypeToExclude":3},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_abstract_mid_dual"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_abstract_mid_dual" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":6,"adSection":"abstract","adPosition":"mid","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> <div class="widget-WidgetLoader widget-instance-AMA_JobsAd"> <div class="SCM-SharedWidgets-AsyncJobsAdLoader" data-url="/AMA/JobsAd/AMA_JobsAd" data-params="{"parameters":{"siteId":3},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> <h4 class="thm-col-sec">Others Also Liked</h4> <div id="trendmd-suggestions"></div> </div> </div> <div class="ymal--footer"> <div class="widget-WidgetLoader widget-instance-AMA_PersonalizedContent_AbstractView_Footer"> <div class="SCM-SharedWidgets-AsyncWidgetLoader" data-url="/Personalization/PersonalizedContent/AMA_PersonalizedContent_AbstractView_Footer" data-params="{"parameters":{"resourceIdToExclude":2800656,"resourceTypeToExclude":3},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="manage-interest"> <div class="widget-ManageCollectionInterests widget-instance-ManageCollectionInterests_Magazine"> <div class="manage-interests-modal reveal-modal small modal" data-reveal> <div class="manage-interests--header"> <div class="widget-SelfServeContent widget-instance-AMA_ManageInterests_Header"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="AllSitesManageInterestsHeader" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style> h4 { font-size: 20px !important; } </style> <h4>Select Your Interests</h4> <p>Customize your JAMA Network experience by selecting one or more topics from the list below.</p> </div> </div> </div><div class="manage-interests--categories"> <ul class="category-list"> <li><span class="category-list-item " data-categoryid="46425">Academic Medicine</span></li> <li><span class="category-list-item " data-categoryid="5489">Acid Base, Electrolytes, Fluids</span></li> <li><span class="category-list-item " data-categoryid="5504">Allergy and Clinical Immunology</span></li> <li><span class="category-list-item " data-categoryid="46447">American Indian or Alaska Natives</span></li> <li><span class="category-list-item " data-categoryid="5510">Anesthesiology</span></li> <li><span class="category-list-item " data-categoryid="42143">Anticoagulation</span></li> <li><span class="category-list-item " data-categoryid="6261">Art and Images in Psychiatry</span></li> <li><span class="category-list-item " data-categoryid="42097">Assisted Reproduction</span></li> <li><span class="category-list-item " data-categoryid="42099">Bleeding and Transfusion</span></li> <li><span class="category-list-item " data-categoryid="5548">Cardiology</span></li> <li><span class="category-list-item " data-categoryid="44036">Caring for the Critically Ill Patient</span></li> <li><span class="category-list-item " data-categoryid="6255">Challenges in Clinical Electrocardiography</span></li> <li><span class="category-list-item " data-categoryid="46435">Climate and Health</span></li> <li><span class="category-list-item " data-categoryid="46448">Climate Change</span></li> <li><span class="category-list-item " data-categoryid="44038">Clinical Challenge</span></li> <li><span class="category-list-item " data-categoryid="44039">Clinical Implications of Basic Neuroscience</span></li> <li><span class="category-list-item " data-categoryid="5614">Clinical Pharmacy and Pharmacology</span></li> <li><span class="category-list-item " data-categoryid="46499">Coaching</span></li> <li><span class="category-list-item " data-categoryid="5575">Complementary and Alternative Medicine</span></li> <li><span class="category-list-item " data-categoryid="44040">Consensus Statements</span></li> <li><span class="category-list-item " data-categoryid="46099">Coronavirus (COVID-19)</span></li> <li><span class="category-list-item " data-categoryid="5584">Critical Care Medicine</span></li> <li><span class="category-list-item " data-categoryid="46325">Cultural Competency</span></li> <li><span class="category-list-item " data-categoryid="44019">Dental Medicine</span></li> <li><span class="category-list-item " data-categoryid="5598">Dermatology</span></li> <li><span class="category-list-item " data-categoryid="44011">Diabetes and Endocrinology</span></li> <li><span class="category-list-item " data-categoryid="46320">Diagnostic Test Interpretation</span></li> <li><span class="category-list-item " data-categoryid="46498">Digital Health</span></li> <li><span class="category-list-item " data-categoryid="42054">Drug Development</span></li> <li><span class="category-list-item " data-categoryid="5621">Emergency Medicine</span></li> <li><span class="category-list-item " data-categoryid="5819">End of Life, Hospice, Palliative Care</span></li> <li><span class="category-list-item " data-categoryid="42107">Environmental Health</span></li> <li><span class="category-list-item " data-categoryid="46387">Equity, Diversity, and Inclusion</span></li> <li><span class="category-list-item " data-categoryid="42108">Ethics</span></li> <li><span class="category-list-item " data-categoryid="5644">Facial Plastic Surgery</span></li> <li><span class="category-list-item " data-categoryid="44012">Gastroenterology and Hepatology</span></li> <li><span class="category-list-item " data-categoryid="5664">Genetics and Genomics</span></li> <li><span class="category-list-item " data-categoryid="44041">Genomics and Precision Health</span></li> <li><span class="category-list-item " data-categoryid="5668">Geriatrics</span></li> <li><span class="category-list-item " data-categoryid="5670">Global Health</span></li> <li><span class="category-list-item " data-categoryid="46427">Guide to Statistics and Methods</span></li> <li><span class="category-list-item " data-categoryid="5672">Guidelines</span></li> <li><span class="category-list-item " data-categoryid="5674">Hair Disorders</span></li> <li><span class="category-list-item " data-categoryid="42113">Health Care Delivery Models</span></li> <li><span class="category-list-item " data-categoryid="42114">Health Care Economics, Insurance, Payment</span></li> <li><span class="category-list-item " data-categoryid="42116">Health Care Quality</span></li> <li><span class="category-list-item " data-categoryid="5680">Health Care Reform</span></li> <li><span class="category-list-item " data-categoryid="5830">Health Care Safety</span></li> <li><span class="category-list-item " data-categoryid="5682">Health Care Workforce</span></li> <li><span class="category-list-item " data-categoryid="5679">Health Disparities</span></li> <li><span class="category-list-item " data-categoryid="46328">Health Inequities</span></li> <li><span class="category-list-item " data-categoryid="44020">Health Policy</span></li> <li><span class="category-list-item " data-categoryid="46451">Health Systems Science</span></li> <li><span class="category-list-item " data-categoryid="5688">Hematology</span></li> <li><span class="category-list-item " data-categoryid="5692">History of Medicine</span></li> <li><span class="category-list-item " data-categoryid="5514">Humanities</span></li> <li><span class="category-list-item " data-categoryid="5697">Hypertension</span></li> <li><span class="category-list-item " data-categoryid="44043">Images in Neurology</span></li> <li><span class="category-list-item " data-categoryid="45887">Implementation Science</span></li> <li><span class="category-list-item " data-categoryid="5702">Infectious Diseases</span></li> <li><span class="category-list-item " data-categoryid="44044">Innovations in Health Care Delivery</span></li> <li><span class="category-list-item " data-categoryid="46477">JAMA Forum</span></li> <li><span class="category-list-item " data-categoryid="44070">JAMA Infographic</span></li> <li><span class="category-list-item " data-categoryid="5716">Law and Medicine</span></li> <li><span class="category-list-item " data-categoryid="45308">Leading Change</span></li> <li><span class="category-list-item " data-categoryid="44045">Less is More</span></li> <li><span class="category-list-item " data-categoryid="46327">LGBTQIA Medicine</span></li> <li><span class="category-list-item " data-categoryid="5720">Lifestyle Behaviors</span></li> <li><span class="category-list-item " data-categoryid="45311">Medical Coding</span></li> <li><span class="category-list-item " data-categoryid="5738">Medical Devices and Equipment</span></li> <li><span class="category-list-item " data-categoryid="44023">Medical Education</span></li> <li><span class="category-list-item " data-categoryid="5739">Medical Education and Training</span></li> <li><span class="category-list-item " data-categoryid="5713">Medical Journals and Publishing</span></li> <li><span class="category-list-item " data-categoryid="5746">Melanoma</span></li> <li><span class="category-list-item " data-categoryid="5766">Narrative Medicine</span></li> <li><span class="category-list-item " data-categoryid="5769">Nephrology</span></li> <li><span class="category-list-item " data-categoryid="5777">Neurology</span></li> <li><span class="category-list-item " data-categoryid="44052">Neuroscience and Psychiatry</span></li> <li><span class="category-list-item " data-categoryid="44053">Notable Notes</span></li> <li><span class="category-list-item " data-categoryid="5787">Nursing</span></li> <li><span class="category-list-item " data-categoryid="5788">Nutrition</span></li> <li><span class="category-list-item " data-categoryid="44027">Nutrition, Obesity, Exercise</span></li> <li><span class="category-list-item " data-categoryid="5791">Obesity</span></li> <li><span class="category-list-item " data-categoryid="44013">Obstetrics and Gynecology</span></li> <li><span class="category-list-item " data-categoryid="5796">Occupational Health</span></li> <li><span class="category-list-item " data-categoryid="5801">Oncology</span></li> <li><span class="category-list-item " data-categoryid="5804">Ophthalmology</span></li> <li><span class="category-list-item " data-categoryid="5808">Orthopedics</span></li> <li><span class="category-list-item " data-categoryid="5811">Otolaryngology</span></li> <li><span class="category-list-item " data-categoryid="44028">Pain Medicine</span></li> <li><span class="category-list-item " data-categoryid="46446">Palliative Care</span></li> <li><span class="category-list-item " data-categoryid="44029">Pathology and Laboratory Medicine</span></li> <li><span class="category-list-item " data-categoryid="45306">Patient Care</span></li> <li><span class="category-list-item " data-categoryid="6258">Patient Information</span></li> <li><span class="category-list-item " data-categoryid="5843">Pediatrics</span></li> <li><span class="category-list-item " data-categoryid="44060">Performance Improvement</span></li> <li><span class="category-list-item " data-categoryid="45315">Performance Measures</span></li> <li><span class="category-list-item " data-categoryid="42050">Perioperative Care and Consultation</span></li> <li><span class="category-list-item " data-categoryid="42125">Pharmacoeconomics</span></li> <li><span class="category-list-item " data-categoryid="42126">Pharmacoepidemiology</span></li> <li><span class="category-list-item " data-categoryid="5851">Pharmacogenetics</span></li> <li><span class="category-list-item " data-categoryid="44030">Pharmacy and Clinical Pharmacology</span></li> <li><span class="category-list-item " data-categoryid="5856">Physical Medicine and Rehabilitation</span></li> <li><span class="category-list-item " data-categoryid="42059">Physical Therapy</span></li> <li><span class="category-list-item " data-categoryid="45313">Physician Leadership</span></li> <li><span class="category-list-item " data-categoryid="44061">Poetry</span></li> <li><span class="category-list-item " data-categoryid="45316">Population Health</span></li> <li><span class="category-list-item " data-categoryid="46445">Primary Care</span></li> <li><span class="category-list-item " data-categoryid="45309">Professional Well-being</span></li> <li><span class="category-list-item " data-categoryid="44064">Professionalism</span></li> <li><span class="category-list-item " data-categoryid="5871">Psychiatry and Behavioral Health</span></li> <li><span class="category-list-item " data-categoryid="42128">Public Health</span></li> <li><span class="category-list-item " data-categoryid="5877">Pulmonary Medicine</span></li> <li><span class="category-list-item " data-categoryid="42129">Radiology</span></li> <li><span class="category-list-item " data-categoryid="42058">Regulatory Agencies</span></li> <li><span class="category-list-item " data-categoryid="46443">Reproductive Health</span></li> <li><span class="category-list-item " data-categoryid="5916">Research, Methods, Statistics</span></li> <li><span class="category-list-item " data-categoryid="42142">Resuscitation</span></li> <li><span class="category-list-item " data-categoryid="5896">Rheumatology</span></li> <li><span class="category-list-item " data-categoryid="46326">Risk Management</span></li> <li><span class="category-list-item " data-categoryid="38802">Scientific Discovery and the Future of Medicine</span></li> <li><span class="category-list-item " data-categoryid="46495">Sexual Health</span></li> <li><span class="category-list-item " data-categoryid="5833">Shared Decision Making and Communication</span></li> <li><span class="category-list-item " data-categoryid="5912">Sleep Medicine</span></li> <li><span class="category-list-item " data-categoryid="5915">Sports Medicine</span></li> <li><span class="category-list-item " data-categoryid="5533">Stem Cell Transplantation</span></li> <li><span class="category-list-item " data-categoryid="5921">Substance Use and Addiction Medicine</span></li> <li><span class="category-list-item " data-categoryid="5923">Surgery</span></li> <li><span class="category-list-item " data-categoryid="44065">Surgical Innovation</span></li> <li><span class="category-list-item " data-categoryid="44066">Surgical Pearls</span></li> <li><span class="category-list-item " data-categoryid="44067">Teachable Moment</span></li> <li><span class="category-list-item " data-categoryid="44034">The Art of JAMA</span></li> <li><span class="category-list-item " data-categoryid="44037">The Arts and Medicine</span></li> <li><span class="category-list-item " data-categoryid="6257">The Rational Clinical Examination</span></li> <li><span class="category-list-item " data-categoryid="5936">Tobacco and e-Cigarettes</span></li> <li><span class="category-list-item " data-categoryid="5938">Toxicology</span></li> <li><span class="category-list-item " data-categoryid="46433">Translational Medicine</span></li> <li><span class="category-list-item " data-categoryid="42136">Trauma and Injury</span></li> <li><span class="category-list-item " data-categoryid="5942">Treatment Adherence</span></li> <li><span class="category-list-item " data-categoryid="46323">Ultrasonography</span></li> <li><span class="category-list-item " data-categoryid="5947">Urology</span></li> <li><span class="category-list-item " data-categoryid="44069">Users' Guide to the Medical Literature</span></li> <li><span class="category-list-item " data-categoryid="5950">Vaccination</span></li> <li><span class="category-list-item " data-categoryid="5955">Venous Thromboembolism</span></li> <li><span class="category-list-item " data-categoryid="45312">Veterans Health</span></li> <li><span class="category-list-item " data-categoryid="5957">Violence</span></li> <li><span class="category-list-item " data-categoryid="42139">Women's Health</span></li> <li><span class="category-list-item " data-categoryid="45307">Workflow and Process</span></li> <li><span class="category-list-item " data-categoryid="42140">Wound Care, Infection, Healing</span></li> </ul> </div> <div class="manage-interests--save-preferences"> <div class="save-preferences-btn thm-bg "> <span class="save-preferences-btn-text fw-b">Save Preferences</span> </div> </div> <div class="manage-interests--privacy-terms"> <a class="manage-interests--privacy-terms-color" href="/pages/privacy-policy">Privacy Policy</a> | <a class="manage-interests--privacy-terms-color" href="/pages/terms-of-use">Terms of Use</a></div> <a class="close-reveal-modal icon-close"></a> </div> </div> </div> </section> <section id="secFooterControl" class="master-footer"> <script> var App = App || {}; function scmByClass(className) { return document.getElementsByClassName(className); } function scmById(id) { return document.getElementById(id); } function scmquery(selector) { return document.querySelector(selector); } function queryAll(selector) { return document.querySelectorAll(selector); } function isTrueString(string) { if (typeof string === 'string') { return string.toLowerCase() === 'true'; } return undefined; } function updateViewportDimensions() { var w = window, d = document, e = d.documentElement, g = d.getElementsByTagName('body')[0], x = w.innerWidth || e.clientWidth || g.clientWidth, y = w.innerHeight || e.clientHeight || g.clientHeight; return { width: x, height: y }; } var viewport = updateViewportDimensions(); var debounce = function (func, wait, immediate) { var timeout; return function () { var context = this, args = arguments; var later = function () { timeout = null; if (!immediate) func.apply(context, args); }; var callNow = immediate && !timeout; clearTimeout(timeout); timeout = setTimeout(later, wait); if (callNow) func.apply(context, args); }; }; (function (App) { App.mobileUpperBreakpoint = 767; App.mobileAltBreakpoint = 640; App.mobileMinBreakpoint = 547; App.tabletUpperBreakpoint = 1023; function setVariables() { viewport = updateViewportDimensions(); App.isMobile = (viewport.width <= App.mobileUpperBreakpoint); App.isMobileAlt = (viewport.width <= App.mobileAltBreakpoint); App.isTablet = (viewport.width > App.mobileUpperBreakpoint && viewport.width <= App.tabletUpperBreakpoint); App.isTabletDown = (viewport.width <= App.tabletUpperBreakpoint); App.isDesktop = (viewport.width > App.tabletUpperBreakpoint); App.activeViewport = App.isMobile ? 'small' : App.isTablet ? 'med' : 'large'; } setVariables(); App.cachedViewport = App.isMobile ? 'small' : App.isTablet ? 'med' : 'large'; App.isAnyArticle = !!(scmByClass('widget-ArticleFullView').length || scmByClass('pg_abstract').length || scmByClass('widget-MagazineView').length || scmByClass('widget-ChannelsMagazineView').length); App.isSplitScreen = !!scmByClass('widget-ArticleFullView').length; App.isArticleRedesign = !!scmByClass('widget-ArticleWrapper').length; App.isAbstract = !!scmByClass('pg_abstract').length; App.isMag = !!(scmByClass('widget-MagazineView').length); App.isChannel = !!(scmByClass('channel-site').length); App.isChannelMag = !!(scmByClass('widget-ChannelsMagazineView').length); App.isFreeArticle = !!(scmquery('.widget-ArticleTopInfo .free-access') || scmquery('.widget-ArticleTopInfo .open-access') || scmquery('.widget-ArticleTopInfo .icon-free') || scmquery('.widget-ChannelsMagazineView .free-access')); App.isTollFreeAccess = false; App.isIssue = !!scmByClass('pg_issue').length || !!scmByClass('pg_newonline').length || !!scmByClass('pg_currentissue').length || !!scmByClass('pg_pastissues').length; App.isNewOnline = !!scmByClass('pg_newonline').length; App.isCurrentIssue = !!scmByClass('pg_currentissue').length; App.isPastIssues = !!scmByClass('pg_pastissues').length; App.isJournal = !!scmByClass('pg_journal').length; App.isNetworkHome = !!scmByClass('pg_index').length; App.isSearch = !!scmByClass('pg_searchresults').length; App.isAdvancedSearch = !!scmByClass('pg_advancedsearch').length; App.isPlayer= !!scmByClass('pg_multimediaplayer').length; App.isSelfServe = !!scmByClass('pg_sspage').length; App.isCmsPage = !!scmByClass('pg_cmspage').length; App.isMyAccount = !!scmByClass('pg_myaccount').length; App.supportsFlexbox = !!scmByClass('flexbox').length; App.isCollection = !!scmByClass('pg_collection').length; App.isPaidUser = isTrueString(scmById('hfAppIsPaidUser').getAttribute('value')); App.isMember = isTrueString(scmById('hfAppIsMember').getAttribute('value')); App.isIndividual = isTrueString(scmById('hfAppIsIndividual').getAttribute('value')); App.hasAccess = isTrueString(scmById('hfAppHasAccess').getAttribute('value')); App.isReferredFromGoogle = isTrueString(scmById('hfAppIsReferredFromGoogle').getAttribute('value')); var subscribedTo = scmById('hfAppSubscribedTo').getAttribute('value'); App.userSubscribedTo = subscribedTo ? subscribedTo.split(',') : undefined; App.isLucy = isTrueString(scmById('hfAppIsLucy').getAttribute('value')); App.currentJournalCount = 27; App.isChannelPage = !!(scmByClass('channels-page')); App.updateAppVariables = debounce(function () { setVariables(); }, 50, false); })(App); </script> <div class="footer-ad-wrapper"> <div id="BodyContent_Footer_divAds" class="footer-ad desktop-only"> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_AnchorboardAd_btf"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_AnchorboardAd_btf" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":11,"adSection":"abstract","adPosition":"btf","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> </div> <div class="ad-riser-wrap desktop-only"> <div class="ad-riser--dismiss t-c">X</div> <div class="widget-WidgetLoader widget-instance-AMA_AdTag_Riser"> <div class="SCM-SharedWidgets-AsyncAdLoader" data-url="/AMA/AdTag/AMA_AdTag_Riser" data-params="{"parameters":{"siteName":"jama","siteId":3,"journalId":67,"adDisplay":12,"adSection":"abstract","adPosition":"Riser","fromGoogle":false},"dynamicParameters":{"localParams":"[REPLACE_WITH_LOCAL]"}}"></div> </div> </div> <div class="footer-wrap"> <footer class="footer" id="footer"> <div id="footer-microsite" class="footer-microsite"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Left" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> @media (min-width: 1024px) {.split-screen .footer-microsite-contents {border-bottom:0 !important;}} .footer-microsite-contents {margin-bottom:1em;width:100%;} .footer-network-other .link-apps:before {width: 23px;} .footer-network-other .link-institutions-librarians:before {width: 23px;} .jn-ss-footer-border-top {border-top:1px solid #555;padding-top:15px;} .jn-ss-footer-border-bottom {border-bottom:1px solid #555;padding-bottom:10px;padding-right:3px;} </style> <div class="footer-heading-wrap"> <h3 id="BodyContent_Footer_h3SiteName" class="footer-heading is-b footer-microsite-heading" data-mobile-tog-target=".footer-microsite-links-wrap">JAMA</h3> </div> <div class="footer-microsite-links-wrap"> <div class="footer-microsite-contents jn-ss-footer-border-bottom"> <h4 id="BodyContent_Footer_ContentHeader" class="footer-subheading">Content</h4> <a href="/journals/jama">Home</a> <a href="/journals/jama/newonline">New Online</a> <a href="/journals/jama/currentissue">Current Issue</a> </div> <div class="footer-microsite-contents jn-ss-footer-border-bottom"> <h4 class="footer-subheading">Podcasts</h4> <a href="/journals/jama/pages/covid-19-interviews#audio">Coronavirus (COVID-19) Q&A</a> <a href="/journals/jama/pages/jama-clinical-reviews">Clinical Reviews</a> <a href="/journals/jama/pages/jama-editors-summary">Editors' Summary</a> <a href="/journals/jama/pages/jama-medical-news">Medical News</a> <a href="/journals/jama/pages/jama-author-interviews">Author Interviews</a> <a href="/journals/jama/pages/jamaevidence-jama-guide-to-statistics-and-methods">JAMAevidence: <em>JAMA Guide to Statistics and Methods</em></a> <a href="/journals/jama/pages/jamaevidence-the-rational-clinical-examination">JAMAevidence: The Rational Clinical Examination</a> <a href="/journals/jama/pages/jamaevidence-users-guides-to-the-medical-literature">JAMAevidence: Users' Guides to the Medical Literature</a> </div> <div class="footer-microsite-services cf"> <h4 id="BodyContent_Footer_ServiceHeader" class="footer-subheading">Journal Information</h4> <a href="/journals/jama/pages/for-authors">For Authors</a> <a href="/journals/jama/pages/jama-editors">JAMA Editors</a> <a href="/journals/jama/editors-and-publishers">Editors & Publishers</a> <a href="/pages/rss">RSS</a> <a href="/journals/jama/pages/contact-us">Contact Us</a> </div> <div class="footer-network-other jn-ss-footer-border-bottom"> <a href="https://edhub.ama-assn.org/jn-learning" class="link-network-other is-b link-learning">JN Learning / CME</a> <a href="https://store.jamanetwork.com" class="link-network-other is-b link-store" target="_blank">Store</a> <a href="/pages/apps" class="link-network-other is-b link-mobile" target="_blank">Apps</a> <a href="https://careers.jamanetwork.com/" class="link-network-other is-b link-jobs" target="_blank">Jobs</a> <a href="/pages/resources-for-librarians" class="link-network-other is-b link-institutions-librarians" target="_blank">Institutions</a> <a href="/pages/reprints-and-permissions" class="link-network-other is-b link-reprints-permissions">Reprints & Permissions</a> </div> <div id="BodyContent_Footer_divSubscribe" class="footer-microsite-subscribe"> <img src="//cdn.jamanetwork.com/UI/app/img/covers/jama.jpg" class="subscribe-image" alt="Journal Cover"> <div class="subscribe-meta"> <h4 class="subscribe-heading footer-subheading">Subscribe</h4> <a href="https://store.jamanetwork.com/productDetails.aspx?productcodeID=64" class="subscribe-submit btn">Go</a> </div> </div> </div> </div> <div id="footer-network" class="footer-network"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Middle" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .footer-network-sites {width: 62.85542%;} .footer-network-info {width: 35.93976%} .jn-ss-subheading-mt {margin-top: 1.5em;} .jn-registered:after {content: "\00AE";font-size: 50%;vertical-align: top;} .jn-trademark:after {content: "\2122";font-size: 50%;vertical-align: top;} .nav-logo-cme-signin-container .nav-logo .site-logo img { min-width:50px;} </style> <div class="footer-heading-wrap"> <h3 class="footer-heading is-b jn-registered" data-mobile-tog-target=".footer-network-links-wrap"><strong>JAMA</strong> Network</h3> </div> <div class="footer-network-links-wrap"> <div class="footer-network-sites"> <div class="internal"> <h4 id="BodyContent_Footer_JournalHeader" class="footer-subheading">Publications</h4> <a href="/journals/jama">JAMA</a> <a href="/journals/jamanetworkopen" target="_blank">JAMA Network Open</a> <a href="/journals/jamacardiology">JAMA Cardiology</a> <a href="/journals/jamadermatology">JAMA Dermatology</a> <a href="/journals/jama-health-forum">JAMA Health Forum</a> <a href="/journals/jamainternalmedicine">JAMA Internal Medicine</a> <a href="/journals/jamaneurology">JAMA Neurology</a> <a href="/journals/jamaoncology">JAMA Oncology</a> <a href="/journals/jamaophthalmology">JAMA Ophthalmology</a> <a href="/journals/jamaotolaryngology">JAMA Otolaryngology–Head & Neck Surgery</a> <a href="/journals/jamapediatrics">JAMA Pediatrics</a> <a href="/journals/jamapsychiatry">JAMA Psychiatry</a> <a href="/journals/jamasurgery">JAMA Surgery</a> <a href="/journals/archneurpsyc">Archives of Neurology & Psychiatry (1919-1959)</a> </div> <div class="external"> <h4 class="footer-subheading">Sites</h4> <div id="BodyContent_Footer_ssFooterSiteMenu"> <div class="selfServe"> <a target="_blank" href="https://sites.jamanetwork.com/art-and-images-in-psychiatry/">Art and Images in Psychiatry</a> <a target="_blank" href="/journals/jama/pages/2023-most-viewed-jama">Best of the JAMA Network</a> <a target="_blank" href="/channels/caring-for-the-critically-ill-patient">Caring for the Critically Ill Patient</a> <a target="_blank" href="/journals/jama/pages/crosswords">Clinical Crosswords from JAMA</a> <a target="_blank" href="/journals/jama/pages/coronavirus-alert">Coronavirus Resource Center</a> <a target="_blank" href="https://ebm.jamanetwork.com/index.html">Evidence-Based Medicine: An Oral History</a> <a target="_blank" href="/pages/fishbein-fellowship">Fishbein Fellowship</a> <a target="_blank" href="/channels/genomics/">Genomics and Precision Health</a> <a target="_blank" href="/pages/health-and-the-2024-us-election">Health and the 2024 US Election</a> <a target="_blank" href="/channels/hypertension">Hypertension</a> <a target="_blank" href="/channels/health-forum/archive">JAMA Forum Archive</a> <a target="_blank" href="https://sites.jamanetwork.com/audio">JAMA Network Audio</a> <a target="_blank" href="/pages/video">JAMA Network Video</a> <a target="_blank" href="/pages/conferences">JAMA Network Conferences </a> <a target="_blank" href="/channels/ai">JAMA+ AI</a> <a target="_blank" href="/pages/jama-summit">JAMA Summit </a> <a target="_blank" href="/journals/jamasurgery/pages/statistics-and-methods">JAMA Surgery Guide to Statistics and Methods</a> <a target="_blank" href="/channels/medical-news">Medical News</a> <a target="_blank" href="/channels/monkeypox">Mpox (Monkeypox)</a> <a target="_blank" href="https://sites.jamanetwork.com/research-ethics/">Research Ethics</a> <a target="_blank" href="/pages/collections">Topics and Collections</a> <a target="_blank" href="/pages/visual-abstracts">Visual Abstracts</a> <a target="_blank" href="/channels/war">War and Health</a> <a target="_blank" href="/channels/womens-health">Women's Health</a> <h4 class="footer-subheading jn-ss-subheading-mt">Featured Articles</h4> <a href="/journals/jama/fullarticle/2781397">CONSERVE 2021 Guidelines for Reporting Trials Modified for the COVID-19 Pandemic</a> <a href="/journals/jama/fullarticle/2808296">Creation and Adoption of Large Language Models in Medicine</a> <a href="/journals/jamaoncology/fullarticle/2787350">Global Burden of Cancer, 2010-2019</a> <a href="/journals/jama/fullarticle/2797443">Global Burden of Long COVID</a> <a href="/journals/jamadermatology/fullarticle/2790344">Global Burden of Melanoma</a> <a href="/journals/jamadermatology/fullarticle/2787350">Global Burden of Skin Diseases, 1990-2017</a> <a href="/journals/jamaneurology/fullarticle/2793874">Global Disparities in Parkinson Disease</a> <a href="/journals/jama/fullarticle/2799547">Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension</a> <a href="/journals/jamapsychiatry/fullarticle/2799486">Mass Violence and the Complex Spectrum of Mental Illness and Mental Functioning</a> <a href="/journals/jamapsychiatry/fullarticle/2793903">Neuropsychiatry Sequelae of COVID-19</a> <a href="/journals/jamaneurology/fullarticle/2810313">A New Framework for Dementia Nomenclature</a> <a href="/journals/jama/fullarticle/2800656">Organization and Performance of US Health Systems</a> <a href="/journals/jama-health-forum/fullarticle/2791195">Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy</a> <a href="/journals/jama-health-forum/fullarticle/2791195">Promoting EDI in Genetics Research</a> <a href="/journals/jamacardiology/fullarticle/2781972">PTSD and Cardiovascular Disease</a> <a href="/journals/jama/fullarticle/2810754">Red Blood Cell Transfusion: 2023 AABB International Guidelines</a> <a href="/journals/jamapediatrics/fullarticle/2797600">Reimagining Children’s Rights in the US</a> <a href="/journals/jama/fullarticle/2794049">Spirituality in Serious Illness and Health</a> <a href="/journals/jama/fullarticle/2796374">The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity</a> <h4 class="footer-subheading jn-ss-subheading-mt">USPSTF Recommendation Statements</h4> <a href="/journals/jama/fullarticle/2779985">Screening for Colorectal Cancer</a> <a href="/journals/jama/fullarticle/2779190">Screening for Hypertension</a> <a href="/journals/jama/fullarticle/2777244">Screening for Lung Cancer</a> <a href="/journals/jama/fullarticle/2796244">Screening for Prediabetes and Type 2 Diabetes In Children</a> <a href="/journals/jama/fullarticle/2783414">Screening for Prediabetes and Type 2 Diabetes In Adults</a> <a href="/journals/jama/fullarticle/2795521">Statins for Primary Prevention of Cardiovascular Disease</a> <a href="/journals/jama/fullarticle/2793446">Vitamin and Mineral Supplements for Primary Prevention of of Cardiovascular Disease and Cancer</a> <h4 class="footer-subheading jn-ss-subheading-mt">Blogs</h4> <a target="_blank" href="https://amastyleinsider.com/">AMA Style Insider</a> </div> </div> </div> </div> <div id="footer-network-info" class="footer-network-info"> <div class="information-for-links"> <h4 id="BodyContent_Footer_InfoHeader" class="footer-subheading">Information</h4> <a href="/pages/for-authors">For Authors</a> <a href="/pages/resources-for-librarians">For Institutions & Librarians</a> <a href="/pages/advertisers">For Advertisers</a> <a href="/pages/subscription-agents">For Subscription Agents</a> <a href="https://careers.jamanetwork.com/" target="_blank">For Employers & Job Seekers</a> <a href="https://media.jamanetwork.com" rel="nofollow" target="_blank">For the Media</a> <a href="/pages/equity-diversity-inclusion">Equity, Diversity, Inclusion</a> <a href="/pages/commenting-policy">Online Commenting Policy</a> <a href="/pages/access-at-jama-network">Public Access and Open Access Policy</a> <a href="/pages/offensive-content-statement">Statement on Potentially Offensive Content</a> </div> <div class="services-links"> <h4 id="BodyContent_Footer_JAMANetworkProductsHeader" class="footer-subheading">JAMA Network Products</h4> <a href="http://www.amamanualofstyle.com/" class="footer-service-link" target="_blank">AMA Manual of Style</a> <a href="https://jamaevidence.mhmedical.com/" class="footer-service-link" target="_blank"><span class="jn-registered">JAMAevidence</span></a> <a href="http://www.peerreviewcongress.org/" class="footer-service-link" target="_blank">Peer Review Congress</a> </div> <div class="learning-links"> <h4 id="BodyContent_Footer_LearningHeader" class="footer-subheading">JN Learning</h4> <a href="https://edhub.ama-assn.org/jn-learning">Home</a> <a href="https://edhub.ama-assn.org/jn-learning/state-cme">State CME</a> <a href="https://edhub.ama-assn.org/jn-learning/pages/clinical-challenge-courses">Clinical Challenge CME</a> <a href="https://edhub.ama-assn.org/jn-learning/course/288 ">Atrial Fibrillation Course</a> <a href="https://edhub.ama-assn.org/jn-learning/course/294 ">Women's Health Course</a> <a target="_blank" href="https://edhub.ama-assn.org/pages/auto-credit-reporting">CME / MOC Reporting Preferences</a> <a href="https://edhub.ama-assn.org/jn-learning/pages/about-cme">About CME & MOC</a> </div> </div> </div> </div> <div id="footer-resources-wrap" class="footer-resources-wrap"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Right" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .footer-resources-wrap .footer-subheading {color: grey;display:block !important;font-size: 1.17647em;font-weight: 400;text-transform: uppercase;} </style> <div class="footer-heading-wrap"> <h3 class="footer-heading is-b footer-resources-heading" data-mobile-tog-target=".footer-resources">Help</h3> </div> <div class="footer-resources"> <a href="https://store.jamanetwork.com" class="footer-service-link" target="_blank">Subscriptions & Renewals</a> <a href="https://jamanetwork.com/oauthsignin?return_url=http%3A%2F%2Fjamanetwork.com%2Fmyaccount%23my-alerts" class="footer-service-link" rel="nofollow">Manage Emails</a> <a href="https://jamanetwork.com/oauthsignin?return_url=http%3A%2F%2Fjamanetwork.com%2Fmyaccount%23my-profile" class="footer-service-link" rel="nofollow">Update My Address</a> <a href="https://support.jamanetwork.com/hc/en-us" class="footer-service-link">Support Center</a> <a href="/myaccount " class="footer-service-link">My Account</a> <h4 class="footer-subheading jn-ss-subheading-mt">JAMA Career Center</h4> <a href="https://careers.jamanetwork.com/" class="footer-service-link" target="_blank">Physician Job Listings</a> </div> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Socials" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .widget-instance-AMA_Journal_Home_Socials .iconsocial {display: inline-block !important;width: 34px;height: 34px;min-width: unset !important;margin: 0 2px !important;background-color: #fff;border-radius: 20px;border: 1px solid #191919;vertical-align: middle;} .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-black.svg);background-position: 7px 7px;background-repeat: no-repeat;background-size: 18px;} .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram:hover, .widget-instance-AMA_Journal_Home_Socials .iconsocial.instagram:focus {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-fill.png);border-color: #C13584;} .footer-resources-wrap .iconsocial {display: inline-block !important;width: 32px;height: 32px;min-width: unset !important;margin: 0 2px 0 3px !important;background-color: #fff;border-radius: 20px;border: 1px solid #191919;vertical-align: middle;} .footer-resources-wrap .iconsocial.instagram {background-image: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-black.svg);background-position: 6px 6px;background-repeat: no-repeat;background-size: 18px;} .footer-resources-wrap .iconsocial.instagram:hover, .footer-resources-wrap .iconsocial.instagram:focus {background-color: #C13584;border-color: #191919;} #load-instagram-image { background: url(https://cdn.jamanetwork.com/ImageLibrary/JamaNetwork/social/instagram-icon-fill.png) no-repeat -9999px -9999px; } </style> <div id="BodyContent_Footer_divSocial" class="social-links footer-social-links"> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.facebook.com/JAMAJournal/" class="social-link is-b facebook"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://twitter.com/JAMA_current" class="social-link is-b twitter"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.instagram.com/jamanetwork/?hl=en" class="iconsocial instagram"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.linkedin.com/company/jamanetwork/" class="social-link is-b linked-in"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.youtube.com/jamanetwork" class="social-link is-b you-tube"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://www.pinterest.com/jamanetwork/" class="social-link is-b pinterest"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="/rss/site_3/67.xml" class="social-link is-b rss"></a> <a target="_blank" rel="nofollow" data-emailid="6d35777a-fc12-4d2d-9b49-81d031835d91" href="https://jamanetwork.com/journals/jama/pages/jama-editors-summary" class="social-link is-b podcast"></a> <div id="load-instagram-image"> </div> </div> <div id="BodyContent_Footer_divEmailUpdate" class="footer-email-updates"> <div class="widget-EmailListSignUp widget-instance-AMAv2_EmailListSignUp_Footer"> <div class="email-signup"> <div class="email-signup--text sb-pc">Get the latest from JAMA</div> <div class="email-signup--input-wrap is-b"> <input type="text" name="email" class="email-signup--input" placeholder="Email address" title="Email address" /> <a rel="nofollow" href="javascript:;" class="email-signup--submit sb-sc btn">Sign Up</a> </div> <div class="email-signup--link"> <a class="email-signup--privacy" href="/pages/privacy-policy">Privacy Policy</a> | <a class="email-signup--terms" href="/pages/terms-of-use">Terms of Use</a></div> <div class="email-signup--user-message"></div> </div> </div> </div> </div> <div class="footer-bar" itemscope itemtype="https://schema.org/Organization"> <input type="hidden" class="SelfServeContentId" value="v2_Footer_Bottom_Bar" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <style type="text/css"> .network-bar .auth--inst {color:#B8B8B8;} .multimedia-caption-container div.video-caption {color: #262626;font-size: 15px;font-weight: 700;line-height: 1.5;} .nav-journals a.theme-jama-health-forum:before {background: #133763;} .jn-bottom-bar {color: #fff; float: left;font-size: 10px;padding: 13px 20px;width: 33.33%;} .jn-bottom-bar p {line-height: 2;} @media (max-width: 900px) {.jn-bottom-bar {float: none;width: 100%;}} .jn-footer-copyright {font-size:12px;line-height:1.5;margin-bottom:10px;} .jn-footer-pipe {margin:0 10px;} .footer-bar-jn-logo img {width: 230px;} @media (max-width: 900px) {.footer-bar-jn-logo img {width: 200px;}} [data-thm=umb] .jobs-ad--text h6 {color: #d71635 !important;} [data-thm=jama] .jobs-ad--text h6 {color: #d71635 !important;} [data-thm=jaman] .jobs-ad--text h6 {color: #ed0973 !important;} [data-thm=cardi] .jobs-ad--text h6 {color: #be1e32 !important;} [data-thm=derm] .jobs-ad--text h6 {color: #006f3b !important;} [data-thm=faci] .jobs-ad--text h6 {color: #ed1c24 !important;} [data-thm=jama-] .jobs-ad--text h6 {color: #fb5252 !important;} [data-thm=intem] .jobs-ad--text h6 {color: #006e96 !important;} [data-thm=neur] .jobs-ad--text h6 {color: #981b1e !important;} [data-thm=oncol] .jobs-ad--text h6 {color: #3b923f !important;} [data-thm=ophth] .jobs-ad--text h6 {color: #66bc29 !important;} [data-thm=otol] .jobs-ad--text h6 {color: #34b6e4 !important;} [data-thm=peds] .jobs-ad--text h6 {color: #0084c0 !important;} [data-thm=psych] .jobs-ad--text h6 {color: #005276 !important;} [data-thm=surg] .jobs-ad--text h6 {color: #f47920 !important;} .blockquote .para {margin: 0 0 1em 1em;} .jn-footer-copyright {display: block;} .inline-block {display: inline-block;} </style> <a class="footer-bar-jn-logo d-b no-mw mb1" href="/" title="JAMA Network Home"><img class="mw-100" src="https://cdn.jamanetwork.com/ImageLibrary/global/jn-signature-reversed-r.svg?versionId=82308" alt="Jama Network Logo"></a> <div class="jn-bottom-bar"> <p> <span class="jn-footer-copyright">© 2024 American Medical Association. <span class="inline-block">All rights reserved,</span> including those for text and data mining, AI training, <span class="inline-block">and similar technologies.</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/terms-use" rel="nofollow" class="p0">Terms of Use</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/privacy-policy" rel="nofollow" class="p0">Privacy Policy</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a href="https://www.ama-assn.org/about/accessibility-statement" rel="nofollow" class="p0">Accessibility Statement</a><span class="jn-footer-pipe">|</span></span> <span class="inline-block"><a onclick="OneTrust.ToggleInfoDisplay()" rel="nofollow" class="p0" id="CookieFooter">Cookie Settings</a></span> </p> </div>  <a class="footer-bar-sis no-mw relative nudge-down" href="https://www.silverchair.com" target="_blank"><img class="footer-bar-sis-img mt05 mw-100" width="600" height="70" src="//cdn.jamanetwork.com/UI/app/img/powered.png" alt="Silverchair Logo" /></a> </div> </footer> </div> <div class="ss-ui-only"> <div class="widget-SelfServeContent widget-instance-AMA_SS_UI_Only"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SsUiOnly" /> <input type="hidden" class="SelfServeVersionId" value="0" /> . </div> </div> </div> </section> <div id="revealModal" class="reveal-modal" data-reveal> <div id="revealContent"></div> <a class="close-reveal-modal icon-close"></a> </div> <div class="artmet-modal" id="MetricsModal"> <div class="artmet-modal-contents"> <a class="artmet-close-modal">×</a> </div> </div> <div class="widget-SigninModals widget-instance-AMA_SigninModals"> <div class="js-modal-no-access-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Access your subscriptions</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_NoAccess_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_NoAccess_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_NoAccess_SigninModal_PurchaseOptions_NoAccessAndPaidPDF"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_NoAccessAndPaidPDF" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr> <button class="modal--btn js-btn-subscribe-journal" type="button" role="button"> <div class="text-truncate">Subscribe to journal</div> </button> <div class="modal--btn-desc">Get full journal access for 1 year</div> <button class="modal--btn js-btn-purchase-article" type="button" role="button"> <div class="text-truncate">Buy article</div> </button> <div class="modal--btn-desc">Get unlimited access and a printable PDF ($40.00)—<br> <em>Sign in or create a free account</em></div>  </div> </div> <div class="widget-DeepDyve widget-instance-AMA_NoAccess_DeepDyve"> <button type="button" role="button" class="modal--btn js-deepdyve-link hiddenRentalLink" data-deepdyveurl="https://www.deepdyve.com/doc-view?docId=10.1001/jama.2022.24032&fieldName=journal_doi&affiliateId=JAMA" data-doi="10.1001/jama.2022.24032" data-fieldname="journal_doi" data-issneissn="0098-7484" data-affiliate="JAMA">Rent article</button> <div class="modal--btn-desc js-deepdyve-desc hiddenRentalLink">Rent this article from DeepDyve</div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-paid-pdf-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Access your subscriptions</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_PaidPdf_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_PaidPdf_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_PaidPdf_SigninModal_PurchaseOptions_NoAccessAndPaidPDF"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_NoAccessAndPaidPDF" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr> <button class="modal--btn js-btn-subscribe-journal" type="button" role="button"> <div class="text-truncate">Subscribe to journal</div> </button> <div class="modal--btn-desc">Get full journal access for 1 year</div> <button class="modal--btn js-btn-purchase-article" type="button" role="button"> <div class="text-truncate">Buy article</div> </button> <div class="modal--btn-desc">Get unlimited access and a printable PDF ($40.00)—<br> <em>Sign in or create a free account</em></div>  </div> </div> <div class="widget-DeepDyve widget-instance-AMA_PaidPDF_DeepDyve"> <button type="button" role="button" class="modal--btn js-deepdyve-link hiddenRentalLink" data-deepdyveurl="https://www.deepdyve.com/doc-view?docId=10.1001/jama.2022.24032&fieldName=journal_doi&affiliateId=JAMA" data-doi="10.1001/jama.2022.24032" data-fieldname="journal_doi" data-issneissn="0098-7484" data-affiliate="JAMA">Rent article</button> <div class="modal--btn-desc js-deepdyve-desc hiddenRentalLink">Rent this article from DeepDyve</div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-free-pdf-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Sign in to access free PDF</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-AmaAdvancedSeamlessAccess widget-instance-AMA_FreePdf_AdvancedSeamlessAccessButton"> <div class="seamless-access-button--wrap"> <button class="d-flex sa-button align-items-center" role="button" type="button"> <div class="sa-button-logo-wrap"> <img src="//cdn.jamanetwork.com/UI/app/svg/seamless-access.svg" class="sa-button-logo" alt="Seamless Access Logo" /> </div> <div class="d-flex justify-content-center align-items-center sa-button-text text-truncate"> <div class="sa-button-text-primary text-truncate">Access through your institution</div> </div> </button> <div class="sa-access-text text-truncate hide"> <div class="sa-cta-access"><span>Add or change institution</span></div> </div> </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_FreePdf_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-save-search-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Save your search</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_SaveSearch_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_SaveSearch"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_SaveSearch" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Purchase access</div> <hr /> <button class="modal--btn js-btn-subscribe-now">Subscribe now</button>  </div> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-follow-collection-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Customize your interests</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_FollowCollection_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_FollowCollection"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_FollowCollection" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--sub-title">Create a personal account or sign in to:</div> <ul> <li>Register for email alerts with links to free full-text articles</li> <li>Access PDFs of free articles</li> <li>Manage your interests</li> <li>Save searches and receive search alerts</li> <ul>  </div> </div> <div class="modal--link-wrap"> <a class="modal--link" href="/pages/privacy-policy" rel="nofollow">Privacy Policy</a> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="js-modal-user-comment-reveal no-access reveal-modal modal tiny" data-reveal> <div class="modal--box"> <div class="modal--title">Make a comment</div> <hr /> <button type="button" role="button" class="modal--btn js-btn-signin-personal" data-oauth-signin-url="https://jamanetwork.com/oauthsignin?return_url=https%3a%2f%2fjamanetwork.com%2fjournals%2fjama%2ffullarticle%2f2800656"> Sign in<span class="fw-normal"> | personal account</span> </button> <div class="widget-SelfServeContent widget-instance-AMA_UserComment_SigninModal_CreateAccount"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_CreateAccount" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--title">Free access to newly published articles</div> <hr> <button class="modal--btn js-btn-create-personal-account" type="button" role="button"> <div class="text-truncate">Create a free personal account</div> </button> <div class="modal--btn-desc">To register for email alerts, access free PDF, and more</div>  </div> </div> <div class="widget-SelfServeContent widget-instance-AMA_SigninModal_PurchaseOptions_UserComment"> <div class="self-serve"> <input type="hidden" class="SelfServeContentId" value="SigninModal_PurchaseOptions_UserComment" /> <input type="hidden" class="SelfServeVersionId" value="0" /> <div class="modal--sub-title">Create a personal account or sign in to:</div> <ul> <li>Register for email alerts with links to free full-text articles</li> <li>Access PDFs of free articles</li> <li>Manage your interests</li> <li>Save searches and receive search alerts</li> <ul>  </div> </div> <div class="modal--link-wrap"> <a class="modal--link" href="/pages/privacy-policy" rel="nofollow">Privacy Policy</a> </div> </div> <a class="close-reveal-modal icon-close"></a> </div> <div class="hidden-true js-modal-page-data" data-store-url="https://store.jamanetwork.com" data-store-purchase-url="https://jamanetwork.com/oauthsignin?return_url=https://store.jamanetwork.com" data-store-subscribe-url="https://store.jamanetwork.com/index.aspx?productcode=64"> </div> </div> <script src="//cdn.jamanetwork.com/UI/app/vendor/jquery-2.2.4.min.js?v=638654734634555810"></script> <script>window.jQuery || document.write('<script src="/UI/app/vendor/jquery-2.2.4.min.js">\x3C/script>')</script> <script src="//cdn.jamanetwork.com/UI/app/dist/app.min.js?v=638677764559592887" defer></script> <script src="//cdn.jsdelivr.net/chartist.js/latest/chartist.min.js" type="text/javascript"></script> <script src="//d1bxh8uas1mnw7.cloudfront.net/assets/embed.js" type="text/javascript"></script> <script defer src='//js.trendmd.com/trendmd.min.js' data-trendmdconfig='{"element":"#trendmd-suggestions"}'></script> <script type='text/javascript' src='https://platform-api.sharethis.com/js/sharethis.js#property=643701de45aa460012e1032e&product=sop' async='async'></script> </form> <link rel="stylesheet" href="//cdn.jamanetwork.com/UI/app/scss/modules/_trendMD.css"> <div class="widget-CustomJSScript widget-instance-"> <script src="//cdn.jamanetwork.com/ama/ama.proxylogging.js" async></script> </div> </body> </html>

CINXE.COM

Organization and Performance of US Health Systems | Health Care Reform | JAMA | JAMA Network