Bigger health care systems may not mean better care, study finds

Berkeley Way West
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As the COVID-19 pandemic puts additional financial strain on small health care systems nationwide, the trend of larger entities purchasing smaller medical practices is likely to accelerate.

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A recent study co-authored by experts at the UC Berkeley School of Public Health surveyed hundreds of health care providers across the country and found that bigger does not always mean better when it comes to health care systems.

The multimillion dollar study, published in the August issue of “Health Affairs,” surveyed 739 hospitals and 2,190 physician practices and concluded that bigger, more complex health care systems do not necessarily provide better patient care, challenging a popular assumption about health care.

“The conventional wisdom is that larger, more integrated systems would provide a higher quality of care — for the most part we didn’t find that,” said Stephen Shortell, a co-author of the study and co-director of UC Berkeley’s Center for Healthcare Organizational and Innovation Research.

Health care in the United States used to be offered predominantly through independent physicians and small hospitals, said Elliott Fisher, a professor at Dartmouth College and co-author of the study. Today, according to the study, a majority of hospitals and many physicians are a part of larger and more integrated systems.

This trend is likely to accelerate with the COVID-19 pandemic, Fisher said, as canceled elective surgeries and fewer patient visits create a financial strain on smaller hospitals across the nation, which could cause smaller practices to agree to be purchased by larger entities.

Those in favor of financial integration argue that bigger health care systems can provide more coordinated patient care, Fisher said. However, he added, this trend toward bigger health care systems increases the risk of monopolies forming, which can then raise consumer costs.

“The argument that the monopoly systems make is that ‘well, we’re an integrated delivery system, we can deliver better care, so our higher prices are okay,’” Fisher said. “We’ve known that monopoly pricing is the problem. What we weren’t sure about was if there were significant gains in quality.”

According to Shortell, the study found that while independent hospitals, often located in rural areas, were less effective in providing transition care programs for patients than their larger counterparts, independent physician practices were better at screening for social needs such as food insecurity and clinical conditions such as depression and addiction

In each category of health care provider, the study found high variation in health care quality, according to Shortell. Fisher and Shortell both said this variation shows there is room for improvement for health care systems across the country.

Fisher said the study suggests state and federal governments should pay close attention to anti-competitive behavior in health care delivery and treat financial integration as a serious problem.

“(The study) really does suggest that this assertion that to be good you have to be big doesn’t hold water,” Fisher said.

Contact Ruby Sutton at [email protected] and follow her on Twitter at @rubysutton_.