Following hospital mergers, patients in the UK died more frequently and were readmitted more frequently.
For Vox, Dylan Scott writes on health issues. Before joining Vox in 2017, he wrote on health policy for more than ten years, writing for Governing magazine, Talking Points Memo, and STAT.
Hospitals and other healthcare facilities have been concentrating more and more in the US during the last few decades. About half of US hospitals in 2005 belonged to a larger system. Two-thirds were by 2017. The majority of US locations have what is known as a “highly concentrated hospital market,” which implies that a single business controls the majority of the local hospital facilities.
One of the most important trends in American healthcare is this concentration. Patients may have fewer options and pay more as a result. The majority of the recent increases in US health care spending, according to recent study, are being driven by increasing hospital costs. When hospitals are acquired by larger systems, they can remove crucial services, like maternity care, causing people to drive long distances to receive the medical treatment they once could get nearby.
America’s smaller community hospitals, many of which run deficits, have frequently been obliged to investigate mergers with larger health systems in order to keep the doors open, as I noted late last year.
Higher expenses are terrible news. However, it is notoriously challenging to evaluate the clinical effects of these mergers: Does a more congested hospital system also result in subpar treatment? It is challenging to determine how any adjustments to a hospital’s operations following a merger have contributed to any rise in mortality or readmissions because there are many factors at play, and mergers can disrupt the health care market (through those increased pricing).
A recent investigation into hospital mergers in the UK is attempting to answer that query. According to recent research from academics at Cornell University and the University of London, it was discovered that patients are more likely to die during or shortly after a hospital admission once hospitals merge, and they are also more likely to be readmitted a second time soon. The researchers discovered that these increases start to appear within a few months of the merger and continue for at least two years.
Even though the majority of hospitals in the UK are publicly owned, the national government has prioritised mergers in order to improve the performance of the country’s healthcare system by joining together financially troubled hospitals. A UK hospital merger frequently resembles a US hospital merger in practise: Different hospitals that formerly operated under different administration are placed under the control of one board and one senior leadership team.
The magnitude of the mergers’ effects, particularly on mortality, is significant: Compared to the pre-merger mortality rate of 1.4 percent, the likelihood that a patient will pass away while receiving treatment or within 30 days of being discharged increased by 0.4 percentage points, or by 27 percent. Additionally, they have an 11 percent higher chance of being readmitted within 30 days after hospital discharge.
When compared to a sizable control group of UK hospitals that did not experience a merger during that time, the 139 institutions participating in 13 distinct mergers from 2006 to 2015 experienced 60 more fatalities and 140 more readmissions.
The research on how mergers impact the quality of care in the US is sparse and inconsistent. However, the authors contend that the UK and its National Health Service are perhaps an ideal context to research these effects because payment and the mix of payers are unaffected by the merger. That takes out one factor that could throw off similar studies conducted in the US. Because of changes to the NHS that provided patients more options for where to receive care and put hospitals on a set budget for their operations, researchers focused on the years from 2006 to 2015.
In their research, Ashtari Tafti and Hoe extol the unique quality of the UK healthcare system. They also note that their findings are a natural continuation of earlier research that discovered the quality of care was higher in hospital markets with greater competition. To assess whether the outcomes would be repeated in a different health system with a different payment structure, such as the US, they noted that more research is necessary.
I enquired of Hannah Neprash, a health care economist at the University of Minnesota who was not involved in the study, if she believed that the findings from the UK would also apply to the US. She emphasised that the study’s sample size was quite modest (13 mergers affecting 139 acute care hospitals; for context, the UK control group included about 1,100 hospitals and the US has about 5,000 similar facilities). She also referred to some of the specific findings (such as a significantly higher incidence of kidney-related mortality) that need further examination and justification. The researchers also mentioned how specific modifications made to a hospital’s post-merger operations that affected clinical quality should be the focus of further research.
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“For me, there’s still some doubt regarding generalizability, but that’s not particularly due to the variations between hospital-related issues in the US and UK,” she added.
Patients in the US already complain that their care is inferior at hospitals that have undergone mergers. According to this new study, there may also be a quantifiable impact on the more objective quality of care people receive.
Given the unfavourable financial incentives in the US healthcare system, more and more hospitals are joining together in an effort to remain open, run more effectively, and, in principle, provide better patient care coordination. Federal regulators have occasionally attempted to halt those mergers, but they are constrained by a number of factors. In the interim, hospitals have argued to public officials that consolidation actually benefits patients – with little empirical data to refute them.
However, the nagging worry has been that if hospitals have less competition, the quality of care may suffer. According to what Ashtari Tafti and Hoe discovered during their research, regulators should take these worries seriously as they examine upcoming mergers and acquisitions.