This week, PricewaterhouseCooper's Health Research Institute released a new report, From courtship to marriage Part II: How physicians and hospitals are creating sustainable relationships, based on an online survey of approximately 1,000 U.S. physicians as well as 28 in-depth interviews with thought leaders and executives representing healthcare providers, payers and professional associations.

FiercePracticeManagement recently spoke with one of the report's authors, Warren H. Skea, director of PwC's Health Enterprise Growth Practice, about what this research means to physicians.

FPM: Your report set out three keys to a successful alignment: shared governance, aligned compensation and changing practice patterns. Is there a hierarchy or order of importance among these three ideas?

Skea: There may be some things that are more immediate, but I think it's going to be dependent on the situation. They're three legs to the same stool. Ultimately, the integrity of an ongoing relationship between physicians and hospitals is dependent on all three of those. Without a proper balance, or if any one is not a priority, you will affect the integrity of that relationship.

FPM: Were any of the findings surprising to you as a researcher?

Skea: Where I potentially see the chance where there's a misunderstanding, miscommunication or area where there could be a problem in the future, I think that's around expectation around compensation. As the report describes, physicians want to at least maintain or increase their compensation; and there are some instances of declining reimbursements where it's difficult for that to happen. I don't know if that surprised me as much as it highlighted an area where there could be some misaligned perceptions.

FPM: The report talks a great deal about aligning incentives, but are we also talking about sharing risk?

Skea: With the changing reimbursement models and delivery models, taking risk is going to be more of a staple. The good news is the physicians articulated and certainly believe that some of their compensation should be at risk. I think there's going to be more performance and financial risk with models such as [accountable care organizations].

It's about aligning all the incentives, not just risk. So physicians will be measured specifically [on] their actions, [as well as on] the overall performance of the system where they're employed, or if it's an ACO or joint venture. They're going to be taking financial and performance risk along with all of their partners, as in the Dean Clinic example.

FPM: Based on your research, do you think trust between physicians and hospitals is getting better, worse, or staying the same?

Skea: Trust is situationally dependent. Overall, it's probably slowly getting better. But I think if you contrast the three case studies, trust is the foundation upon which these relationships are built. Ultimately you start out with the level of trust, and the alignment model employed hopefully increases that trust. But it's something that takes time. I'd say for those like a Huntsville, I think it does increase that trust, and I happen to be convinced of that because that's a client of mine. Full trust and partnering together under these new delivery models are going to take time.

It's not just aligning incentives and compensation, but governance and physicians being involved in that governance is absolutely critical. The good news on that is that both parties recognize a critical need for physicians to be involved in governance. So there is certainly convergence on that level.

FPM: Will practices that choose to stay independent be affected by the alignment trend?

Skea: Absolutely. Whether they stay independent or not, you're going to have the same or similar reimbursement changes as those that do align with hospitals-partial capitation, capitation, taking shared savings. That's with commercial insurance or Medicare/Medicaid. That's the trend you're seeing fairly consistently across the industry. So whether or not physicians align, the same principles apply: efficiency, quality, outcomes, getting paid for outcomes, managing patients, redesigning the care delivery model and changing practice patterns to fit that new delivery model.

FPM: What do you want to be the top takeaway of the report for physicians considering alignment strategies?

Skea: In the past, reimbursement models were focused on fee for service, and hospitals and physicians were often competitors. Now, we have new post-reform alignment models that are forcing both parties to communicate, collaborate and have some form of shared or aligned incentives as part of the policy objectives to break down those silos of care. Whether physicians want to maintain their private practice or align themselves is somewhat not the issue. The issue is that they need to be thinking about how they can be involved in redesigning those practice patterns and delivery model.

This interview has been edited and condensed for clarity.