The New Palgrave Dictionary of Economics

Living Edition
| Editors: Palgrave Macmillan

Vertical Integration Among Health Care Providers

  • Madeline M. GradeEmail author
  • Laurence Baker
Living reference work entry
First Online:
DOI: https://doi.org/10.1057/978-1-349-95121-5_3070-1
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Abstract

The past decade in the United States has seen considerable interest in and rising prevalence of vertical integration of hospitals and physician practices, especially financially in the form of hospital acquisition of physician groups. In theory, this could yield a range of effects on cost, prices, efficiency, and quality of health delivery, which can be difficult to disentangle empirically. Furthermore, while financial integration may yield clinical integration, it need not. Current evidence often associates vertical integration with increased costs and spending; evidence on quality effects is much more mixed and a number of studies do not find associations between integration and improvements in quality and outcomes. In addition, a number of financial incentives have been implicated as drivers of vertical integration, including provider based billing. Further empirical investigation would be valuable, and discourse on mechanisms for better incentivizing societal value in this changing landscape, including the possibility of further regulatory action, are warranted.

JEL Classification

I10: health, general I11: analysis of health care markets I18: health, government policy, regulation, and public health L40: antitrust issues and policies, general 
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Bibliography

  1. Alpert, A., H. Hsi, and M. Jacobson. 2017. Evaluating the role of payment policy in driving vertical integration in the oncology market. Health Affairs 36: 680–688.  https://doi.org/10.1377/hlthaff.2016.0830.CrossRefGoogle Scholar
  2. Baker, L.C., M.K. Bundorf, and D.P. Kessler. 2014. Vertical integration: Hospital ownership of physician practices is associated with higher prices and spending. Health Affairs 33: 756–763.  https://doi.org/10.1377/hlthaff.2013.1279.CrossRefGoogle Scholar
  3. Baker, L.C., M.K. Bundorf, and D.P. Kessler. 2016. The effect of hospital/physician integration on hospital choice. Journal of Health Economics 50: 1–8.  https://doi.org/10.1016/j.jhealeco.2016.08.006.CrossRefGoogle Scholar
  4. Berenson, R.A. 2017. A physician’s perspective on vertical integration. Health Affairs 36: 1585–1590.  https://doi.org/10.1377/hlthaff.2017.0848.CrossRefGoogle Scholar
  5. Berenson, R.A., P.B. Ginsburg, and N. Kemper. 2010. Unchecked provider clout in California foreshadows challenges to health reform. Health Affairs 29: 1–7.  https://doi.org/10.1377/hlthaff.2009.0715.CrossRefGoogle Scholar
  6. Bishop, T.F., S.M. Shortell, P. Patricia, et al. 2016. Trends in hospital ownership of physician practices and the effect on processes to improve quality. The American Journal of Managed Care 22: 172–176.Google Scholar
  7. Burns, L.R., and R.W. Muller. 2008. Hospital–physician collaboration: Landscape of economic integration and impact on clinical integration. The Milbank Quarterly 86: 375–434.  https://doi.org/10.1111/j.1468-0009.2008.00527.x.CrossRefGoogle Scholar
  8. Burns, L.R., and M.V. Pauly. 2018. Transformation of the health care industry: Curb your enthusiasm? The Milbank Quarterly 96: 57–109.  https://doi.org/10.1111/1468-0009.12312.CrossRefGoogle Scholar
  9. Burns, L.R., J.C. Goldsmith, and A. Sen. 2013. Horizontal and vertical integration of physicians: A tale of two tails. Advances in Health Care Management 15: 39–117.  https://doi.org/10.1108/S1474-8231(2013)0000015009.CrossRefGoogle Scholar
  10. Capps, C., D. Dranove, and C. Ody. 2017. Physician practice consolidation driven by small acquisitions, so antitrust agencies have few tools to intervene. Health Affairs 36: 1556–1563.  https://doi.org/10.1377/hlthaff.2017.0054.CrossRefGoogle Scholar
  11. Capps, C., D. Dranove, and C. Ody. 2018. The effect of hospital acquisitions of physician practices on prices and spending. Journal of Health Economics 59: 139–152.  https://doi.org/10.1016/j.jhealeco.2018.04.001.CrossRefGoogle Scholar
  12. Carlin, C.S., B. Dowd, and R. Feldman. 2015. Changes in quality of health care delivery after vertical integration. Health Services Research 50: 1043–1068.  https://doi.org/10.1111/1475-6773.12274.CrossRefGoogle Scholar
  13. Carlin, C., R. Feldman, and B. Dowd. 2016. The impact of hospital acquisition of physician practices on referral patterns. Health Economics 25: 439–454.CrossRefGoogle Scholar
  14. Carlin, C.S., R. Feldman, and B. Dowd. 2017. The impact of provider consolidation on physician prices. Health Economics 26: 1789–1806.  https://doi.org/10.1002/hec.3502.CrossRefGoogle Scholar
  15. Ciliberto, F., and D. Dranove. 2006. The effect of physician–hospital affiliations on hospital prices in California. Journal of Health Economics 25: 29–38.  https://doi.org/10.1016/j.jhealeco.2005.04.008.CrossRefGoogle Scholar
  16. Conti, R.M., M.B. Landrum, and M. Jacobson. 2016. The impact of provider consolidation on outpatient prescription drug-based cancer care spending, 1–11. Portland: National Academy for State Health.Google Scholar
  17. Cuellar, A.E., and P.J. Gertler. 2006. Strategic integration of hospitals and physicians. Journal of Health Economics 25: 1–28.  https://doi.org/10.1016/j.jhealeco.2005.04.009.CrossRefGoogle Scholar
  18. Cunningham, P.J., and J. Hadley. 2008. Effects of changes in incomes and practice circumstances on physicians’ decisions to treat charity and Medicaid patients. The Milbank Quarterly 86: 91–123.CrossRefGoogle Scholar
  19. Dafny, L.S., and T.H. Lee. 2016. Health care needs real competition. Harvard Business Review 94: 76–87.Google Scholar
  20. Desai, S., and J.M. McWilliams. 2018. Consequences of the 340B Drug Pricing Program. The New England Journal of Medicine 378: 539–548.  https://doi.org/10.1056/NEJMsa1706475.CrossRefGoogle Scholar
  21. Dranove, D., and C. Ody. 2016. Employed for higher pay? How Medicare facility fees affect hospital employment of physicians. Evanston: Northwestern University.Google Scholar
  22. Federal Trade Commission. 2014. St. Luke’s Health Care System v. FTC, No. 14-35173 (9th Cir.): Brief of Amicus Curie the States of California, Washington, Pennsylvania, Connecticut, Delaware, Illinois, Iowa, Kentucky, Maine, Maryland, Mississippi, Montana, Nevada, New Mexico, Oregon, and Tennessee. https://www.ftc.gov/system/files/documents/cases/140820statesbrief.pdf.
  23. Forlines, G.L. 2017. Trends and drivers of physician–hospital integration: The role of Medicare reimbursement. Lexington: University of Kentucky.Google Scholar
  24. Fuse Brown, E., and J. King. 2016. The double-edged sword of health care integration: Consolidation and cost control. Indiana Law Journal 92: 55–112.Google Scholar
  25. Gaynor, M. 2014. Competition policy in health care markets: Navigating the enforcement and policy maze. Health Affairs 33: 1088–1093.  https://doi.org/10.1377/hlthaff.2014.0333.CrossRefGoogle Scholar
  26. Gaynor, M. 2018. Examining the impact of health care consolidation: statement before the Committee on Energy and Commerce Oversight and Investigations Subcommittee. U.S. House of Representatives. https://docs.house.gov/meetings/IF/IF02/20180214/106855/HHRG-115-IF02-Wstate-GaynorM-20180214.pdf.
  27. Gaynor, M., and P.B. Ginsburg. 2017. Making health care markets work: Competition policy for health care. SSRN Electronic Journal.  https://doi.org/10.2139/ssrn.2964912.
  28. Gaynor, M., and R. Town. 2012. The Impact of Hospital Consolidation - Update. The Synthesis Project 9: 1–8.  https://doi.org/10.13140/RG.2.1.4294.0882.
  29. Glied, B.S.A., and S.H. Altman. 2017. Beyond antitrust: Health care and health insurance market trends and the future of competition. Health Affairs 9: 1572–1577.  https://doi.org/10.1377/hlthaff.2017.0555.CrossRefGoogle Scholar
  30. Greaney, T.L. 2017. Coping with concentration. Health Affairs 36: 1564–1571.  https://doi.org/10.1377/hlthaff.2017.0558.CrossRefGoogle Scholar
  31. Hussey, P.S., S. Wertheimer, and A. Mehrotra. 2013. The association between health care quality and cost: A systematic review. Annals of Internal Medicine 158: 27–34.  https://doi.org/10.7326/0003-4819-158-1-201301010-00006.CrossRefGoogle Scholar
  32. Koch, T.G., B.W. Wendling, and N.E. Wilson. 2017. How vertical integration affects the quantity and cost of care for Medicare beneficiaries. Journal of Health Economics 52: 19–32.  https://doi.org/10.1016/j.jhealeco.2016.12.007.CrossRefGoogle Scholar
  33. Koch, T.G., B.W. Wendling, and N.E. Wilson. 2018. Physician market structure, patient outcomes, and spending: An examination of Medicare beneficiaries. Health Services Research 53 (5): 3549–3568.  https://doi.org/10.1111/1475-6773.12825.CrossRefGoogle Scholar
  34. Kocher, R., and N.R. Sahni. 2011. Hospitals’ race to employ physicians – The logic behind a money-losing proposition. The New England Journal of Medicine 364: 1790–1793.  https://doi.org/10.1056/NEJMp1101959.CrossRefGoogle Scholar
  35. Kralewski, J., B. Dowd, D. Knutson, et al. 2015. The relationships of physician practice characteristics to quality of care and costs. Health Services Research 50: 710–729.  https://doi.org/10.1111/1475-6773.12242.CrossRefGoogle Scholar
  36. Lammers, E. 2013. The effect of hospital–physician integration on health information technology adoption. Health Economics 22: 1215–1229.  https://doi.org/10.1002/hec.2878.CrossRefGoogle Scholar
  37. Levinson, D.R. 2016. CMS is taking steps to improve oversight of provider-based facilities, but vulnerabilities remain. Washington, DC: Department of Health and Human Services.Google Scholar
  38. MedPAC. 2016. Medicare payment policy. Report to the Congress, 71–78. Washington, DC: MedPAC.Google Scholar
  39. Neprash, H.T., M.E. Chernew, A.L. Hicks, et al. 2015. Association of financial integration between physicians and hospitals with commercial health care prices. JAMA Internal Medicine 175: 1–8.  https://doi.org/10.1001/jamainternmed.2015.4610.CrossRefGoogle Scholar
  40. O’Malley, A.S., A.M. Bond, and R.A. Berenson. 2011. Rising hospital employment of physicians: Better quality, higher costs? Center for Studying Health System Change 136: 1–4.Google Scholar
  41. Pesko, M.F., A.M. Ryan, S.M. Shortell, et al. 2017. Spending per Medicare beneficiary is higher in hospital-owned small- and medium-sized physician practices. Health Services Research 53 (4): 2133–2146.  https://doi.org/10.1111/1475-6773.12765.CrossRefGoogle Scholar
  42. Polsky, D., M. Richards, S. Basseyn, et al. 2015. Appointment availability after increases in Medicaid payments for primary care. The New England Journal of Medicine 372: 537–545.  https://doi.org/10.1056/NEJMsa1413299.CrossRefGoogle Scholar
  43. Post, B., T. Buchmueller, and A. M. Ryan. 2017. Vertical integration of hospitals and physicians: Economic theory and empirical evidence on spending and quality. Medical Care Research and Review 107755871772783.  https://doi.org/10.1177/1077558717727834.CrossRefGoogle Scholar
  44. Richards, M.R., S.S. Nikpay, and J.A. Graves. 2016. The growing integration of physician practices – With a Medicaid side effect. Medical Care 54: 714–718.  https://doi.org/10.1097/MLR.0000000000000546.CrossRefGoogle Scholar
  45. Roberts, E.T., A. Mehrotra, and J.M. McWilliams. 2017. High-price and low-price physician practices do not differ significantly on care quality or efficiency. Health Affairs 36: 855–864.  https://doi.org/10.1377/hlthaff.2016.1266.CrossRefGoogle Scholar
  46. Robinson, J.C., and K. Miller. 2014. Total expenditures per patient in hospital-owned and physician-owned physician organizations in California. JAMA 312: 1663–1669.  https://doi.org/10.1001/jama.2014.14072.CrossRefGoogle Scholar
  47. Scott, K.W., E.J. Orav, D.M. Cutler, and A.K. Jha. 2017. Changes in hospital–physician affiliations in U.S. hospitals and their effect on quality of care. Annals of Internal Medicine 166: 1–8.  https://doi.org/10.7326/M16-0125.CrossRefGoogle Scholar
  48. Song, Z., J. Wallace, H.T. Neprash, et al. 2015. Medicare fee cuts and cardiologist–hospital integration. JAMA Internal Medicine 175: 1229–1231.  https://doi.org/10.1001/jamainternmed.2015.2017.CrossRefGoogle Scholar
  49. Sowers, K.W., P.R. Newman, and J.C. Langdon. 2013. Evolution of physician–hospital alignment models: A case study of comanagement. Clinical Orthopaedics and Related Research 471: 1818–1823.  https://doi.org/10.1007/s11999-013-2911-0.CrossRefGoogle Scholar
  50. Tollen, L. 2008. Physician organization in relation to quality and efficiency of care: A synthesis of recent literature, 1121. New York: The Commonwealth Fund.Google Scholar
  51. Trybou, J., P. Gemmel, and L. Annemans. 2015. Provider accountability as a driving force towards physician–hospital integration: A systematic review. International Journal of Integrated Care 15: e010.  https://doi.org/10.5334/ijic.1582.CrossRefGoogle Scholar
  52. Wagner, A.R. 2016. Effect of physician–hospital financial integration on health outcomes and spending. Evanston: Northwestern University.Google Scholar
  53. Walden, E. 2016. Can Hospitals Buy Referrals? The Impact of Physician Group Acquisitions on Market-Wide Referral Patterns. https://www.semanticscholar.org/paper/Can-Hospitals-Buy-Referrals-The-Impact-of-Physician-Walden/97f36a8841c1651b29af228a8c91665035c7f20f.

Copyright information

© The Author(s), under exclusive license to Springer Nature Limited 2020

Authors and Affiliations

  1. 1.University of California San FranciscoSan FranciscoUSA
  2. 2.Department of Health Research and PolicyStanford University School of MedicineStanfordUSA

Section editors and affiliations

  • Barbara Wolfe
    • 1
  1. 1.University of WisconsinMadisonUSA