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Improved health care value cannot be achieved by hospital mergers and acquisitions alone
New study finds that only about one in five health care integrations leads to improved value of care delivery
Key Takeaways
- A new study finds little evidence that hospital mergers and acquisitions reduce costs or improve quality of care.
- More strategic quality improvement efforts are needed for patients to benefit from health care integration.
CHICAGO (December 30, 2024) — Mergers and acquisitions of U.S. hospitals and health systems rarely improve the quality of care delivered or result in lower health care costs and prices, according to a study published in the Journal of the American College of Surgeons (JACS).
The study, a systematic review of hundreds of published studies, comes amid accelerating health care integration, sometimes called consolidation. Nearly 70 percent of U.S. hospitals are now affiliated with a health system.
“Proponents of health care integration have claimed it controls costs and enhances care quality,” said lead study author Bhagwan Satiani, MD, MBA, FACS, professor of surgery emeritus at The Ohio State University Wexner Medical Center, Columbus, Ohio. “But we found that evidence is lacking that integration alone is an effective strategy for improving the value of health care delivery.”
The study results send a clear message to health care leaders, Dr. Satiani said.
“These findings provide an opportunity to better define value with a focus on benefiting patients while balancing the financial stability of the health care industry,” he said. “Quality improvement in health care cannot be achieved by mergers and acquisitions alone.”
Effects of Health Care Integration
The authors’ systematic review included studies published from 2000-2024. Of these, 37 met inclusion criteria. Among the 26 studies that measured quality of care, nearly 77 percent (20 studies) showed reduced quality or no change due to integration, the investigators reported. Only 23 percent (six studies) showed improved quality, primarily due to better care management processes rather than outcomes. Just one study found fewer patient deaths after integration.
Hospital charges increased with integration 93 percent of the time, according to 13 of 14 studies measuring price changes. Of 16 studies assessing health care spending, 81 percent (13 studies) showed higher costs or no change.
The researchers also reported the net impact of integration on quality, price, and spending:
- Only eight of 37 studies (22 percent) showed that health care integration had a positive (improved) net impact.
- More than half (54 percent, 20 studies) showed a negative (worse) net impact.
In noting limitations of their review, Dr. Satiani said none of the reviewed studies used standard measures of quality, price, or spending. Also, most studies did not explore reasons for a lack of change in health care value after integration.
How this Study Differs from Previous Research
Although other researchers have reached similar conclusions, Dr. Satiani said their study differed in two ways. First, most studies of health care integration appear in health policy and economics publications and do not reach many surgeons, he noted. Yet, surgical services affect health organizations’ bottom line, accounting for about one third of U.S. health care expenditures.
“Surgical outcomes also have a direct impact on overall health care quality,” he said.
Second, Dr. Satiani said few of the published studies were systematic reviews, which are intended to reduce bias.
In this study, after screening 1,297 U.S. articles published from 1990 to 2024, the investigators systematically reviewed 384 of them that discussed either horizontal or vertical health care integration. They defined horizontal integration as two or more hospitals merging and vertical integration as hospitals acquiring independent physician practices.
To be included in the review, articles must have reported at least one of three measures of value: quality, price, and spending. Quality referred both to patient outcomes, such as the number of 30-day readmissions or deaths, and to care management processes. Such processes included staffing levels and use of nurse care managers. Price denoted the amount the organization charges the consumer per hospitalization, and spending was the organization’s costs per patient.
Focus on Quality Improvement
Dr. Satiani said health care leaders should delineate organizational resources and infrastructure to quality improvement efforts and standardize quality metrics. As a model for quality improvement, he suggested the American College of Surgeons Quality Verification Program as a model improving surgical quality.
Study coauthors are David Way, MEd; David Hoyt, MD, FACS; and E. Christopher Ellison, MD, FACS.
The study authors have no relevant disclosures.
This study is published as an article in press on the JACS website.
Citation: Satiani B, Way DP, Hoyt DE, Ellison EC. A Systematic Review of Integration Strategies Across the U.S. Healthcare System Shows No Consistent Improvement in Price, Cost Reduction, or Quality of Care. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000001229
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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
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Journal
Journal of the American College of Surgeons
Article Title
A Systematic Review of Integration Strategies Across the U.S. Healthcare System Shows No Consistent Improvement in Price, Cost Reduction, or Quality of Care
Article Publication Date
30-Dec-2024
Billing patients for portal messages could decrease message volume and ease physician workload
Peer-Reviewed PublicationBelow please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.
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1. Billing patients for portal messages could decrease message volume and ease physician workload
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01711
URL goes live when the embargo lifts
A retrospective observational study found that a program that enabled billing patients for portal messages slightly decreased the volume of patient-initiated messages. The results suggest portal message billing could help to reduce portal message burden, which contributes to provider burnout. The study is published in Annals of Internal Medicine.
Researchers from the Mayo Clinic studied data between 18 August 2023 through 18 February 2024 to determine the effects of the implementation of billing for patient-initiated portal messages on patients and physicians and advanced practice providers at Mayo Clinic sites in four U.S. states. The researchers compared the results with electronic health record (EHR) data from the same period between 2022 and 2023. Portal messages eligible for e-billing met the following criteria: patient-initiated, established patient, new or multiple symptoms or concerns, and requiring 5 minutes or more to assess and respond. Before sending a portal message, a pop-up screen notified the patient of the potential to be billed for a response to the message. The researchers identified all instances where a patient initiated a message and viewed the billing disclaimer. They then compared the use of Mayo Clinic facilities, including emergency departments and outpatient office visits, in the seven days after viewing the billing disclaimer and proceeding to send a message versus those who did not. Finally, the researchers conducted an online survey to assess providers’ perceptions of billing for patient portal messages. The results found that implementation of e-visit billing was associated with an 8.8% decrease in patient-initiated medical advice messages between the two time periods. Only 0.3% of medical advice messages were ultimately billed, and there was no difference in 7-day use of emergency services in patients who sent a message versus those who did not after viewing the billing disclaimer. Providers with experience using e-visit billing reported overall acceptance of the process, however, 66.1% of providers did not perceive an effect on the volume of messages received. These findings suggest that billing for portal messages is both feasible and acceptable to providers and has potential to decrease provider workload.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Shannon M. Dunlay, MD, MS please email Vincent Jacobbi at Jacobbi.Vincent@mayo.edu.
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2. ACP develops framework to standardize approach, use of economic evidence for clinical guidelines
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02149
URL goes live when the embargo lifts
The American College of Physicians (ACP), in recognition of accelerating health care spending and the impact on patients, has developed a framework that aligns with ACP principles of promoting high-value care, to standardize its approach to identifying, appraising, and considering economic evidence in the development of ACP clinical guidelines. The framework is published in Annals of Internal Medicine.
The framework presents and explains the process that ACP’s Clinical Guidelines Committee (CGC) utilizes for incorporating economic evidence into clinical recommendations. Eligible economic evidence includes cost-effectiveness analyses, economic outcomes in randomized controlled trials, and resource utilization (intervention cost) data. To develop a clinical recommendation, the committee first and foremost assesses the best available evidence for the clinical net benefit of interventions, weighing the benefits and harms. In addition, patient values and preferences play a major role in formulating the recommendations. After assessing if an intervention has clinical net benefit, economic evidence may be considered in prioritizing among recommended interventions of equal effectiveness or modifying the strength of recommendations. The committee’s goal is to always inform clinicians about intervention cost to enhance awareness about the burden on our patients and support shared cost-conscious prescribing in real-life settings.
ACP has been a global leader in the development of clinical guidelines and advancing science and methods. This framework represents a new advancement in guideline development that will continue to ensure that clinical recommendations consider factors important for physician, patient, public, and health system decision-making to deliver and receive high-value, sustainable health care.
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please contact Andrew Hachadorian at ahachadorian@acponline.org.
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Also new in this issue:
The Nuances of Performance Measurement and Clinical Guidelines
Amir Qaseem, MD, PhD, MHA et al.
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02092
Medical Reference Tools and Pharmaceutical Promotion: A History of Entanglement
Andrew S. Lea, MD, DPhil; Jai Krishan Khurana, AB, AM
History of Medicine
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01959
Misinformation, Identity, and the Basis of Belief
Dhruv Khullar, MD, MPP; Dannagal G. Young, PhD
Ideas and Opinions
Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-02844
Journal
Annals of Internal Medicine
Method of Research
News article
Subject of Research
People
Article Title
Implementation of Billing for Patient Portal Messages as e-Visits in a Large Integrated Health System
Article Publication Date
31-Dec-2024
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