In many instances in which hospitals have purchased or affiliated with others in their region, there has been little or no real integration, a pair of health policy experts contends.
Hospital leaders who say they must consolidate with their competitors and other providers to achieve integration and improve quality are misstating reality, says a Harvard health policy researcher.
Not only is integration achieved in other ways, but for the nation, consolidation drives up costs and leaves patients with fewer choices when fewer systems dominate their markets.
Hospital leaders "often are touting consolidation as the way to achieve integration, but they're really not the same thing," says Ashish Jha, MD, of the Department of Health Policy and Management at the Harvard School of Public Health and Brigham and Women's Hospital.
In fact, he says, in many cases in which hospitals have purchased or affiliated with others in their region, there has been little or no real integration.
"There's lots of places where I've seen acquisition but no integration. Yes, you own the hospital, but you don't actually share clinical data, you don't share best practices," he says. "You're part of the same organization technically, but you still have completely fragmented systems of care."
Jha and Thomas Tsai, MD, also of Harvard, made this and several related points in an opinion piece published in JAMA July 1.
"If you want to get integration, you need to have information flow," Jha explained in an interview. "And there are many ways of doing that, by sharing data and best practices, and through health information exchanges. The idea that 'we need to buy other hospitals in order to share our data' is smoke," Jha says. "There's nothing about ownership that's a necessity for integrated care."
Jha refutes two other ideas surrounding the notion that hospital mergers are necessary for better care:
1. Mergers result in higher volumes of certain procedures, which automatically results in higher quality.
Not necessarily, Jha says. In fact, higher volume is only associated with better outcomes in only a few highly specialized and technically difficult surgeries such as esophagectomies and pancreatectomies. Most hospitals do sufficient numbers of most other procedures to reach proficiency without having to merge or affiliate with another organization.
"If you look at studies by (University of Michigan physician researchers) Justin Dimick, MD, and John Berkmeyer, MD on surgical outcomes, what they find is what really differentiates top hospital providers from mediocre ones. And it's not such big differences in complications occurring per se, it's how quickly complications are recognized and how quickly they are addressed," with systems like rapid response teams.
And those systems aren't unique to larger organizations.
2. Mergers enable organizations to spend money on tools such as electronic health records.
Jha says that while smaller hospitals have adopted electronic health record systems at lower rates than larger hospitals in the past, they are now catching up, and keeping up with larger hospitals in the rates of adoption, and meeting meaningful use requirements at the same levels.
"One can always point to individual stories and anecdotes, but the fact of the matter is, a lot of smaller hospitals are able to do this very well."
Jha and Tsai write that quality improvement "does not necessarily depend on expensive technologies, but rather results from engaged leadership that prioritizes quality and works to achieve better care.
"Many quality improvement interventions, such as checklists, are relatively inexpensive, although they require a commitment to effective implementation, data collection, and focusing on monitoring and evaluation," they wrote.
A more effective way to achieve quality improvement, Jha and Tsai say, is to implement policies that strengthen and tighten payment reforms that already exist under the Patient Protection and Affordable Care Act. These include higher penalties for adverse events such as hospital-acquired infections and mortality rates within 30-days of hospital discharge.
"We have lots of activity happening on payment reform," Jha says. "But in my mind, the problem is that we have a mix of measures that vary in terms of value. Some things are really, really important, like mortality and infection rates, while some things much less valuable, like process measures. And some measures that are at odds with each other, like 30-day mortality and 30-day readmission measures, which don't always go in the same direction."
Jha was asked if hospital acquisitions and affiliations might stimulate more aggressive peer pressure, resulting in more skillful surgeons and clinicians at one institution teaching their new colleagues better techniques, then weeding out those that can't improve.
That can happen, he says, and for some hospitals, consolidation, affiliation, or acquisition—whatever you want to call it—has led to better outcomes. But always, and it isn't necessary to improve patient care.
"The way I'd ask that question is, 'Why did we allow a hospital where there were quality issues—say a surgeon botching surgeries—to exist in the first place? What system failure tolerates that? My point is simply that we now have a system that tolerates too much failure, and lets too many organizations perform badly, provide poor quality of care, and get away with it."