New evidence on the impacts of cross-market hospital mergers on commercial prices and measures of quality.

Objective: To examine the impact of "cross-market" hospital mergers on prices and quality and the extent to which serial acquisitions contribute to any measured effects.

Data Sources: 2009-2017 commercial claims from the Health Care Cost Institute (HCCI) and quality measures from Hospital Compare.

Study Design: Event study models in which the treated group consisted of hospitals that acquired hospitals further than 50 miles, and the control group was hospitals that were not part of any merger activity (as a target or acquirer) during the study period.

Private Equity-Acquired Physician Practices And Market Penetration Increased Substantially, 2012-21.

Private equity (PE) firms have been acquiring physician practices at an increasing rate, raising concerns about such firms' penetration at the physician level into local markets and the impact on health care quality and prices. However, limited knowledge exists about the extent of PE firms' control in local markets. By linking data on PE acquisitions to physician data and using full-time-equivalent physicians as the base of assessment, we estimated the local market share of each PE firm within ten physician specialties at the Metropolitan Statistical Area (MSA) level.

The Rise Of Cross-Market Hospital Systems And Their Market Power In The US.

Although hospital consolidation within markets has been well documented, consolidation across markets has not, even though economic theory predicts-and evidence is emerging-that cross-market hospital systems raise prices by exerting market power across markets when negotiating with common customers (primarily insurers). This study analyzes hospital systems using the American Hospital Association Annual Survey Database and defines hospital geographic markets as commuting zones that link workers to places of employment. The share of community hospitals in the US that were part of hospital systems increased from 10 percent in 1970 to 67 percent in 2019, resulting in 3,436 hospitals within 368 systems in 2019.

Effect of State-Led Delivery System and Payment Reforms on Population-Level Detection and Management of Diabetes.

Objective: The Centers for Medicare and Medicaid Services State Innovation Models (SIM) initiative has invested more than $1 billion to test state-led delivery system and payment reforms that can affect diabetes care management. We examined whether SIM implementation between 2013 and 2017 was associated with diagnosed diabetes prevalence or with hospitalization or 30-day readmission rate among diagnosed adults.

Research Design And Methods: The quasiexperimental design compared study outcomes before and after the SIM initiative in 12 SIM states versus five comparison states using difference-in-differences (DiD) regression models of 21,055,714 hospitalizations for adults age ≥18 years diagnosed with diabetes in 889 counties from 2010 to 2017 across the 17 states.

Challenges with Defining Pharmaceutical Markets and Potential Remedies to Screen for Industry Consolidation.

Context: Dramatic increases in pharmaceutical merger and acquisition (M&A) activity since 2010 suggest we are in the midst of a third wave of industry consolidation.

Methods: The authors reviewed 168 economic, legal, medical, industry, and government sources to examine the effects of consolidation on competition and innovation and to explore how industry attributes complicate M&A regulation in a pharmaceutical context.

Findings: The authors find that, in spite of certain metrics that might argue otherwise, consolidation consistently reduces innovation and harms the public good.

Do State Bans of Most-Favored-Nation Contract Clauses Restrain Price Growth? Evidence From Hospital Prices.

Unlabelled: Policy Points Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most-favored-nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices.

States' Merger Review Authority Is Associated With States Challenging Hospital Mergers, But Prices Continue To Increase.

States can challenge proposed hospital mergers by using antitrust laws to prevent anticompetitive harms. This observational study examined additional state laws-principally charitable trust, nonprofit corporation, health and safety, and certificate-of-need laws-that can serve as complements and substitutes for antitrust laws by empowering states to be notified of, review, and challenge proposed hospital mergers through administrative processes. During the period 2010-19, 862 hospital mergers were proposed, but only forty-two (4.

The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence.

This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables.

Assessing the Short-Term Association Between Rural Hospitals' Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance.

Purpose: Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures.

Methods: This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects.

The Early Impact of the Centers for Medicare & Medicaid Services State Innovation Models Initiative on 30-Day Hospital Readmissions Among Adults With Diabetes.

Background: The Centers for Medicare & Medicaid Services (CMS) State Innovation Models (SIM) Initiative funds states to accelerate delivery system and payment reforms. All SIM states focus on improving diabetes care, but SIM's effect on 30-day readmissions among adults with diabetes remains unclear.

Methods: A quasi-experimental research design estimated the impact of SIM on 30-day hospital readmissions among adults with diabetes in 3 round 1 SIM states (N=671,996) and 3 comparison states (N=2,719,603) from 2010 to 2015.

Exploratory analysis of the potential for advanced diagnostic testing to reduce healthcare expenditures of patients hospitalized with meningitis or encephalitis.

Objective: To estimate healthcare expenditures that could be impacted by advanced diagnostic testing for patients hospitalized with meningitis or encephalitis.

Methods: Patients hospitalized with meningitis (N = 23,933) or encephalitis (N = 7,858) in the U.S.

Early Impact of the State Innovation Models Initiative on Diagnosed Diabetes Prevalence Among Adults and Hospitalizations Among Diagnosed Adults.

Background: The State Innovation Models (SIM) Initiative invested $254 million in 6 states in Round 1 to accelerate delivery system and payment reforms.

Objective: The objective of this study was to examine the association of early SIM implementation and diagnosed diabetes prevalence among adults and hospitalization rates among diagnosed adults.

Research Design: Quasi-experimental design compares diagnosed diabetes prevalence and hospitalization rates before SIM (2010-2013) and during early implementation (2014) in 6 SIM states versus 6 comparison states.

Clinical Metagenomic Sequencing for Diagnosis of Meningitis and Encephalitis.

Background: Metagenomic next-generation sequencing (NGS) of cerebrospinal fluid (CSF) has the potential to identify a broad range of pathogens in a single test.

Methods: In a 1-year, multicenter, prospective study, we investigated the usefulness of metagenomic NGS of CSF for the diagnosis of infectious meningitis and encephalitis in hospitalized patients. All positive tests for pathogens on metagenomic NGS were confirmed by orthogonal laboratory testing.

Countywide physician organization learning collaborative and changes in hospitalization rates.

Objectives: In 2011, the California Right Care Initiative implemented a countywide physician organization learning collaborative called University of Best Practices (UBP) in San Diego County for major healthcare systems and physician organizations to share best practices in managing cardiovascular and cerebrovascular risk factors. Our objective was to examine whether UBP was associated with fewer hospitalizations for heart attacks and strokes.

Study Design: A quasi-experimental design was used to compare age-adjusted adult hospitalization rates before UBP initiation (2007-2010) against rates after UBP initiation (2011-2014) in San Diego County versus the rest of California.

Health Care Market Concentration Trends In The United States: Evidence And Policy Responses.

Policy makers and analysts have been voicing concerns about the increasing concentration of health care providers and health insurers in markets nationwide, including the potential adverse effect on the cost and quality of health care. The Council of Economic Advisers recently expressed its concern about the lack of estimates of market concentration in many sectors of the US economy. To address this gap in health care, this study analyzed market concentration trends in the United States from 2010 to 2016 for hospitals, physician organizations, and health insurers.

Consumers Buy Lower-Cost Plans On Covered California, Suggesting Exposure To Premium Increases Is Less Than Commonly Reported.

With the notable exception of California, states have not made enrollment data for their Affordable Care Act (ACA) Marketplace plans publicly available. Researchers thus have tracked premium trends by calculating changes in the average price for plans offered (a straight average across plans) rather than for plans purchased (a weighted average). Using publicly available enrollment data for Covered California, we found that the average purchased price for all plans was 11.

Differing Impacts Of Market Concentration On Affordable Care Act Marketplace Premiums.

Recent increases in market concentration among health plans, hospitals, and medical groups raise questions about what impact such mergers are having on costs to consumers. We examined the impact of market concentration on the growth of health insurance premiums between 2014 and 2015 in two Affordable Care Act state-based Marketplaces: Covered California and NY State of Health. We measured health plan, hospital, and medical group market concentration using the well-known Herfindahl-Hirschman Index (HHI) and used a multivariate regression model to relate these measures to premium growth.

Republican States Bolstered Their Health Insurance Rate Review Programs Using Incentives From the Affordable Care Act.

The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish state-based exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states' rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACA's enactment, we conducted legal research and contacted each state's insurance regulator.

States with stronger health insurance rate review authority experienced lower premiums in the individual market in 2010-13.

States have varying degrees of review authority over health insurance carriers' rates, including prior approval authority over proposed rates and requirements for loss ratios, the proportion of premium revenues spent on medical claims. The Affordable Care Act (ACA) requires carriers in certain categories of health insurance to provide public justification for rate increases of 10 percent or more. We collected data on how states changed their rate review authority and requirements during 2010-13, the years immediately after enactment of the ACA, and we combined these data with carrier filings.

Growth of Accountable Care Organizations in California: Number, Characteristics, and State Regulation.

Accountable care organizations (ACOs) result in physician organizations' and hospitals' receiving risk-based payments tied to costs, health care quality, and patient outcomes. This article (1) describes California ACOs within Medicare, the commercial market, and Medi-Cal and the safety net; (2) discusses how ACOs are regulated by the California Department of Managed Health Care and the California Department of Insurance; and (3) analyzes the increase of ACOs in California using data from Cattaneo and Stroud. While ACOs in California are well established within Medicare and the commercial market, they are still emerging within Medi-Cal and the safety net.

Review of Medicare, Medicaid, and Commercial Quality of Care Measures: Considerations for Assessing Accountable Care Organizations.

Accountable care organizations (ACOs) have proliferated under the Affordable Care Act (ACA). If ACOs are to improve health care quality and lower costs, quality measures will be increasingly important in determining if provider consolidations associated with the development of ACOs are achieving their intended purpose. This article assesses quality measurement across public and private sectors.

State Variation in Increased ADHD Prevalence: Links to NCLB School Accountability and State Medication Laws.

Objective: The study's objective was to investigate whether attention-deficit hyperactivity disorder (ADHD) diagnoses from 2003 to 2011 were associated with either public school consequential accountability reforms initiated by the No Child Left Behind (NCLB) Act, particularly for low-income children, or with state psychotropic medication laws that prohibit public schools from recommending or requiring medication use.

Methods: Logistic regression difference-in-differences models were estimated with repeated U.S.

Informing public policy toward binational health insurance: empirical evidence from California.

Objective: To estimate reimbursement rate differences between Mexico and US based physicians reimbursed by a binational health insurance (BHI) plan and US payers, respectively; and show the relationship between plan benefit designs and health care utilization in Mexico.

Materials And Methods: Data include 33,841 and 53,909 HMO enrollees in California from Sistemas Médicos Nacionales (SIMNSA) and Salud con Health Net, respectively. We use descriptive statistical methods.

Health care supply and county-level variation in attention-deficit hyperactivity disorder prescription medications.

Purpose: Although much literature reports small-area variation in medication prescriptions used to treat attention-deficit hyperactivity disorder (ADHD), scant research has examined factors that may drive this variation. We examine, across counties in the USA, whether the use of prescription medications to treat ADHD varies positively with supply-side healthcare characteristics.

Methods: We retrieved annual prescription data for ADHD medications in 2734 US counties from a nationally representative sample of 35 000 pharmacies in 2001-2003.

International variation in treatment procedures for ADHD: social context and recent trends.

Objective: Scientific and clinical interest in attention-deficit hyperactivity disorder (ADHD) is increasing worldwide. This article presents data from a cross-national workshop and survey related to questions of variability in diagnostic and, particularly, treatment procedures.

Methods: Representatives of nine nations (Australia, Brazil, Canada, China, Germany, Israel, the Netherlands, Norway, and the United Kingdom), plus the United States, who attended a 2010 workshop on ADHD, responded to a survey that addressed diagnostic procedures for ADHD; treated prevalence of medication approaches, as well as psychosocial interventions; types of medications and psychosocial treatments in use; payment systems; beliefs and values of the education system; trends related to adult ADHD; and cultural and historical attitudes and influences related to treatment.