Bigger not always better care

Guest Column:
Shannon Brownlee and Vikas Saini
Hospitals are busily merging with other hospitals and buying up groups of doctors. They claim that size brings efficiency and the opportunity to deliver more “value-based” care – and fewer unnecessary services. They argue that they have to get bigger to cut waste. What’s the evidence that bigger hospitals offer better value? Not a lot. More

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Focus: HEALTH CARE

Bigger not always better care

Guest Column:
Shannon Brownlee and Vikas Saini
Posted 2/24/14

Hospitals are busily merging with other hospitals and buying up groups of doctors. They claim that size brings efficiency and the opportunity to deliver more “value-based” care – and fewer unnecessary services. They argue that they have to get bigger to cut waste. What’s the evidence that bigger hospitals offer better value? Not a lot.

If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts. The Dartmouth Atlas of Health Care and other sources have shown time and again that some of the biggest and best-known U.S. hospitals are no less guilty of subjecting patients to useless tests and marginal treatments.

Larger hospitals are also very good at raising prices. In 2010, an analysis for the Massachusetts attorney general found no correlation between price and quality of care. A study published recently in Health Affairs offered similar results for the rest of the country: On average, higher-priced hospitals are bigger, but offer no better quality of care.

The disconnect between price and value has many causes, but the flurry of mergers and acquisitions in the hospital industry is making it worse. Hospitals command higher prices when they corner market share. They gain even more leverage when they gobble up large physician practices.

Courts are beginning to wake up to these facts. Last year, St. Luke’s Health System Ltd., a multihospital chain based in Boise, Idaho, acquired the state’s largest independent multispecialty physician practice group, Saltzer Medical Group, giving the hospital 80 percent of adult primary-care physicians in the relevant market. On Jan. 24, the U.S. District Court in Idaho ruled that the acquisition violated federal antitrust law, and reversed it.

But the courts aren’t moving fast enough. In many communities, deals between hospitals and physician practices, particularly procedure-oriented specialists, amount to a pact to fleece the system. Hospitals often command higher rates for procedures and tests than do specialists in their private practices. With specialists on a salary, a hospital can charge its higher rates, and the parties split the increased revenue. Everybody wins, except patients and payers.

The phenomenon of buying doctors’ practices is changing health care in ways that go deeper than raising prices. Power is shifting from physicians and other caregivers, whose duty (though they don’t always fulfill it) is to the needs of patients, toward administrators and corporations, whose loyalty lies with the institution or shareholders.

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