Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018.

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes. CONTEXT: The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. METHODS: To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models. FINDINGS: We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. CONCLUSIONS: Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

Quality competition and hospital mergers-An experiment.

On the basis of a Salop model with regulated prices, we investigate quality provision behaviour of competing hospitals before and after a merger. For this, we use a controlled laboratory experiment where subjects decided on the level of treatment quality as head of a hospital. We find that the post-merger average quality is significantly lower than the average pre-merger quality. However, for merger insiders and outsiders, average quality choices are significantly higher than predicted for pure profit-maximising hospitals. This upward deviation is potentially driven by altruistic behaviour towards patients. Furthermore, we find that in the case where sufficient cost synergies are realised by the merged hospitals, there is a significant increase in average quality choices compared to the scenario without synergies. Finally, we find that our results do not change when comparing individual decisions to team decisions.

Merging Two Hospitals: The Effects on Pediatric Extracorporeal Cardiopulmonary Resuscitation Outcomes.

In this article, a retrospective study was performed to describe the impact of merging two pediatric intensive care units on the overall and neurocognitive outcomes of children who required extracorporeal cardiopulmonary resuscitation (ECPR). Results from three cohorts were compared: 2008 to 2014: premerge, 2014 to 2017: initial time period postmerge, and 2018 to 2019: established merge. Survival to hospital discharge (and with good neurological outcome) was of 68% (61%), 46% (36%), and 79% (71%), respectively, for the three time periods. Merging two hospitals resulted in a nonsignificant trend toward temporary worse outcomes in pediatric patients requiring ECPR.

Consolidation Of Providers Into Health Systems Increased Substantially, 2016-18.

Provider consolidation into vertically integrated health systems increased from 2016 to 2018. More than half of US physicians and 72 percent of hospitals were affiliated with one of 637 health systems in 2018. For-profit and church-operated systems had the largest increases in system size, driven in part by a large number of system mergers and acquisitions.

Reproductive health care in Catholic-owned hospitals.

Mergers that affiliate a hospital with a Catholic owner, network, or system reduce the set of possible reproductive medical procedures since Catholic hospitals have strict prohibitions on contraception. Using changes in ownership of hospitals, we find that Catholic hospitals reduce the per bed rates of tubal ligations by 31%, whereas there is no significant change in related permitted procedures such as Caesarian sections. However, across a variety of measures, we find minimal overall welfare reductions. Still, fewer tubal ligations increase the risk of unintended pregnancies across the United States, imposing a potentially substantial cost for less reliable contraception on women and their partners.

Do hospital mergers reduce costs?

Proponents of hospital consolidation claim that mergers lead to significant cost savings, but there is little systematic evidence backing these claims. For a large sample of hospital mergers between 2000 and 2010, I estimate difference-in-differences models that compare cost trends at acquired hospitals to cost trends at hospitals whose ownership did not change. I find evidence of economically and statistically significant cost reductions at acquired hospitals. On average, acquired hospitals realize cost savings between 4 and 7 percent in the years following the acquisition. These results are robust to a variety of different control strategies, and do not appear to be easily explained by post-merger changes in service and/or patient mix. I then explore several extensions of the results to examine (a) whether the acquiring hospital/system realizes cost savings post-merger and (b) if cost savings depend on the size of the acquirer and/or the geographic overlap of the merging hospitals.

The evolution of freestanding children's hospitals in Canada.

OBJECTIVE: The purpose of the present article is to examine the evolution of freestanding children's hospitals in Canada over the past century. The results include documentation of the number of freestanding children's hospitals in Canada that have since closed, merged with other institutions or remained freestanding. Similar data are presented for the United States (US). Also included is an analysis of factors in the internal and external environment that contributed to the changing structure of children's hospitals. METHODS: Sources of information included a review of the literature, publicly available data and statistics on children's hospitals in Canada and the US. RESULTS: Nine of the 16 children's hospitals in Canada were freestanding at one time. Today, only two remain freestanding. Three formerly freestanding children's hospitals have merged with maternal health facilities and four formerly freestanding children's hospitals have merged with adult institutions. Similar trends are seen in the US. CONCLUSIONS: The structure of children's hospitals in North America has changed significantly over the past century. This can be attributed to a number of factors, including the evolution of the health status of children due to medical advances, as well as external forces such as demographics and the rising cost of health care. The impact on the health of children and the mission of children's hospitals in terms of patient care, teaching and research remains to be seen.

Hospital merger control in Germany, the Netherlands and England: Experiences and challenges.

Aiming at the efficiency enhancing and quality improving effects of competition, various steps have been undertaken to foster competition in hospital markets. For these mechanisms to work, robust competition policy needs to be enacted and enforced. We compare the hospital markets in Germany, the Netherlands and England regarding their experience with competition and put a special focus on merger control and the stringency of its implementation. Elaborating on the differences in merger control practice we find that despite very similar goals the respective agencies apply very different approaches and take fundamentally different routes when balancing proclaimed benefits of mergers with potential risks of consolidated markets. While the German competition authority has a strong focus on maintaining the preconditions for competition, in the Netherlands we find over the past decade a much stronger focus on hypothesized countervailing buyer power, accepting in turn highly concentrated markets. In England we find the currently most comprehensive analysis of proposed mergers in combination with a clearly positive assessment of the effects of patient choice and competition on prices and quality. All agencies are still reluctant to implement merger simulation models or similarly advanced econometric methods in their appraisal. One very likely reason is a lack of country specific empirical evidence on these matters.

Factors associated with hospital closure and merger: a survival analysis of Dutch hospitals from 1978 to 2010.

Health policy in most West European countries is directed at transforming the healthcare systems into more self-regulating and competitive systems. After a period of strong regulation, the Dutch government decided to step back and created conditions in which competition could lead to cost management and quality improvement. The question is whether mergers have contributed to the survival chances of hospitals. This paper describes the results of an analysis performed on the survival of all Dutch hospitals in the years 1978 to 2010. The survival of hospitals during this period was determined and their survival rates were calculated statistically. Furthermore, the relation between a hospital's lifespan and a number of predictive variables was investigated. In this study, more detailed consideration is given to the fact of whether a hospital merged with another hospital. Bivariate analysis shows that smaller hospitals in particular have been driven out of the market. The difference in lifespan between hospitals which had merged and those which had not, appeared to be significant. However, a multivariate analysis, when corrected for size, type, and location, showed that merging had no significant effect on hospital lifespan.

Análise da produtividade da política de fusão de unidades hospitalares em Portugal integradas no Serviço Nacional de Saúde / Productivity analysis of hospital mergers in Portuguese National Health System

Objetivo: Avaliar a variação da produtividade dos hospitais sujeitos a uma política de fusão entre os anos 2005 e 2013. Métodos: Para a medição da produtividade recorreu-se ao índice de Malmquist, que considera em simultâneo a variação da eficiência e a variação da tecnologia (fronteira ou melhores práticas). A população-alvo foram os Centros Hospitalares criados entre 2003 e 2010. Os dados de custos e da produção realizada foram obtidos através da revisão crítica da literatura (relatórios de gestão do Ministério da Saúde). Foram comparados os Centros Hospitalares criados antes e depois da fusão com os hospitais que não foram submetidos a este processo. Resultados: 60% dos hospitais não apresentaram melhoria de produtividade com a reforma em estudo. A produtividade média antes da fusão era de 1,004 e após fusão desceu para 0,977. Os hospitais não sujeitos a processo de fusão apresentaram melhores resultados com produtividade média de 0,994. Conclusões: A política de fusão de unidades de saúde não gerou ganhos de produtividade no médio prazo e os resultados em média demonstraram-se menos positivos no período pós fusão.

Objective: Evaluation of the productivity in hospitals merger between 2005 and 2013. Methods: Malmquist index for the measurement of productivity resorted to the Malmquist index. This method considers the simultaneous variation of the efficiency and the variation of technology (best practices). The target population were the hospitals created between 2003 and 2010. Data were obtained from critical literature review (Ministry of Health management reports). The model considers the change in efficiency and the change in technology, achieved on the basis of cost and production data held for the hospital centers created before and after the merger and for comparison with the hospitals that were not merged. Results: 60% of hospitals showed no improvement in productivity with the reform in the study, the average productivity before the merger was 1,004 and after melting down to 0.977. Hospitals not subject to merger process showed better results with an average yield of 0.994. Conclusions: The health units merger policy does not generate productivity gains in the medium term and the results showed on average are less positive.