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Rejoinder to taxonomy of health networks and systems: a reassessment.

In his commentary on the taxonomy of health systems and networks that we originally developed in Bazzoli et al. (1999) and updated through Dubbs et al. (2004), Luke raises various concerns about the underlying concepts, measures, and approaches we used to develop our classification scheme. His primary concerns are: (1) a bias in system assignment occurs because the taxonomy categories capture multimarket configurations of systems rather than centralization per se; (2) hospital service configuration data do not provide relevant information about the locus of health system/network decision making; (3) the conceptual framework used may not be relevant for health networks; and (4) measurement error exists in certain variables. We address each of these issues in this rejoinder. 
 
Before commenting on these points, we note that our primary purpose for developing the taxonomy in the late 1990s was to examine the structure and strategy of health networks and systems as the American Hospital Association (AHA) and others defined them. The AHA had a long history of tracking these organizations, collecting information on multihospital systems starting in the mid-1970s and on health networks beginning in 1993. Over time, the objectives and structure of these organizations changed in response to changing market imperatives. Most notable was the movement in the mid-1990s to develop organized delivery systems in anticipation of the Clinton administration's Health Security Act of 1994 and in response to the growing belief that capitated contracting between providers and health plans would become common. There was widespread acknowledgement among researchers and the industry that the organizations tracked by the AHA were growing more heterogeneous, and this led to concern that health services research that attempted to measure a system or network effect on hospital behavior would provide misleading information given the diversity of these organizations. This sparked our interest, and that of the Agency for Healthcare Research and Quality, which funded our research, in developing tools for researchers, the hospital industry, and policy makers so they could identify and examine more finely grained, homogenous groups of health networks and systems.