While two major merger deals involving the four largest health insurers in the US are being investigated by the Department of Justice, industry experts are debating whether consolidation is good for business and for patients. From MedPage Today.
This article originally appeared in MedPage Today.
The four largest health insurers in the U.S. control the majority of the insurance marketplace, and that has healthcare academics and industry experts debating the pros and cons of consolidation.
Currently, the nation's four largest health insurers control roughly 80% of the private insurance marketplace, said Ed Howard, JD, president of the Alliance for Health Reform. In 2014, the healthcare sector witnessed a total of 1,299 mergers and acquisitions, a small jump from 1,035 in 2013.
"Thepace of consolidation seems to be accelerating as well, and it's attracting the attention of the Federal Trade Commission [FTC] and the Justice Department's Anti-Trust Division," he said during a briefing sponsored by the Commonwealth Fund and the Alliance for Health Reform last week.
Two of the nation's largest health insurance companies recently announced mergers and both deals are being investigated by the Department of Justice. In July, Aetna announced plans to buy Humana for $37 billion. Just a few weeks later, Anthem revealed it was merging with Cigna in a $48 billion deal.
Critics of the mega-mergers argue they will quash competition, cause premiums to rise, benefits to shrink, and sink provider payments.
Advocates argue that large payers will both operate more efficiently and reduce the cost of care.
Victor Fuchs, PhD, a health policy professor at Stanford University in Stanford, Calif. wrote in a recent Wall Street Journal article that "Insurance companies can act as a counterweight and lower prices will get passed along to consumers instead of increasing insurance-company profits." Peter Lee, executive director of California's Covered Health exchange, co-authored the editorial.
Thomas "Tim" Greaney, JD, a professor at St. Louis University School of Law, who spoke at the briefing said this logic may be sound, but most insurers aren't likely to follow it.
"There is some evidence that large insurers get better discounts from providers, but there's also good evidence that they don't pass that on to the consumers because the insurers have market power," he said.
While it's important not to ignore the impact of health insurance mergers, the issue of provider mergers may have even greater consequences and inflict "greater harm" on health spending, according to some panelists.
Laurence Baker, PhD, professor of health research and policy at Stanford University, said at the briefing that the number of physician practices with more than 100 doctors has nearly doubled from 14% in 2000 to 27% in 2011.
"Large practices with more resources may be better able to coordinate care by multiple providers, more rapidly implement process improvements, more effectively harness technological advances, and more quickly identify new strategies that benefit more patients," he wrote in a recent study co-authored with Daniel Austin, MD of the University of California San Francisco.
There's also a downside to these mergers. Baker's study, which looked at prices paid by private insurers for 15 popular procedures, such as cataract removal, vasectomy, and knee replacement, showed that having a higher concentration of physicians in a geographic area actually increased the price of services.
"Counties with the highest average physician concentrations had prices 8-26 percent higher than prices in the lowest counties," the study noted.
Proponents of provider mergers, such as Bruce Vladeck, PhD, senior advisor at Nexera, a New York-based healthcare consulting firm, argued that consolidation on the delivery side is "a good thing for the quality of healthcare."
However since the topic is so emotionally heated, there continues to be "cognitive dissonance" around consolidation and outcomes, he said, despite the "triple aim" of the Affordable Care Act (ACA), which looks to improve quality, cost, and care.
He cited the success of companies like Kaiser Health and Geisinger. "One of the things about these high performing health systems is that they're not cheap. They're not the lowest-priced competitors in any of their markets," he said. However, a three- or four-person physician practice could not afford to build a patient-centered medical home.
Vladeck also told the story of a family member who was diagnosed with a rare form of cancer. A major medical center misdiagnosed his relative because no one who was capable of reading the patient's pathology slides. The relative then visited the National Cancer Institute, where the patient received the proper diagnosis and treatment, and had "a good outcome," Vladeck said.
He pointed out that the more procedures that a medical center does, the better their outcomes.
Greaney said he understood the drive for consolidation and why some critics say the ACA actually encouraged it, but he added that he's counting on the FTC to draw the line.
"Everybody agreed to reduce fragmentation, but not to monoliths," he stated. "Everything in the ACA is designed to rely on a network of provider competition and insurer competition and without it, it falls apart."