Consolidation is primarily a business decision that is made to increase monopoly or exercise rigorous control. Over the years, the health care industry has been a constant witness to mergers and acquisitions, such as hospitals buying individual physician practices or small group practices, smaller pharmaceutical companies being acquired by larger ones and mergers between insurance giants. A more recent trend has seen health insurance companies merging with or acquiring pharmacies and physician practices, which can be described as a vertical integration.
Some examples include:
- CVS Health, which owns a large chain of pharmacies, acquired the health plan Aetna. CVS runs MinuteClinics in many of its retail locations, which are walk-in clinics.
- UnitedHealth Care (UHC)
- UHC’s subsidiary OptumCare bought DaVita Medical Group, a primary and urgent care chain. The Federal Trade Commission approved the merger with some restrictions to prevent a monopoly that could harm consumers.
- UHC also bought Surgical Care Affiliates, a chain of outpatient surgery centers.
This has created an integrated network of doctor’s practices, urgent care and surgery centers that UHC enrollees can be directed to.
- Humana
- Humana bought Family Physicians Group which provides primary care services to Medicare and Medicaid enrollees in and around Orlando.
- The company has a stake in Kindred at Home, a home health and hospice care chain.
- It also has a stake in the hospice care provider, Curo Health Services.
“Health care mergers may be a good business decision for big corporations, but they should not come at a cost for patients,” says Terry Wilcox, executive director of Patients Rising, a nonprofit patient advocacy organization. “Forcing patients to change their treating physician is not a patient-centered policy.”
What’s at Stake?
Value. Insurance plans are now demanding value for care in the form of their patient’s health outcomes.
Dan Mendelson of Avalere Health writes that payers have realized the value of paying for patient outcomes rather than for procedures. Insurers want to pay the doctors for treating a patient (enrolled with the said insurance company) only if the patient’s health improves, not for the number of tests and procedures that are conducted on that patient. The focus is on holistic patient care instead of treating individual episodes. So, by buying a practice, the insurer/payer has greater control of daily operations. Mendelson advises that not all practices will be of interest to payers; their focus will be on:
- Physician-led groups
- Strong primary care practices
- Practices with diverse specialty care
- Practices that collect and analyze patient data and use it to improve patient outcomes
Will this increase hurdles for patient access to services or specific treatment? Will patients find it more difficult to get their prescription medicines?
A news report from New Jersey says that United Health Group, which owns UHC and Optum, is forcing its Medicaid enrollees to move away from their regular, long-term physician and start visiting doctors at its Optum-owned medical practice. “It seems like they [UHC] are steering patients away from small, community-based doctors to large groups that they own,” Lawrence Downs, CEO, Medical Society of New Jersey, told NJ.com. For patients, this would mean severing long-term relations and the trust that they build with their doctors.
The company told NJ.com that this was a cost-cutting move for UHC.
The Pros:
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- Insurers would have more control over data to know what’s working and what’s not in a physician practice
- Insurers can use the consolidated data to assist enrollees to achieve a smooth continuum of care
- Patient-members could potentially use e-visits/telehealth and have greater access to an integrated health care system and broader access to services and specialists
- Some insurers may offer discounts, such as no co-pay, for its members who go to the insurer’s urgent care clinics. Aetna members that visit CVS’ MinuteClinics, for example, do not have a co-pay
The Cons:
- Patients will be forced to visit insurance-recommended doctors, which could limit choices
- Loss of trust factor in the patient-physician relation, especially for patients who may have been visiting a practice for a long time
- Could care quality be compromised?
Are you facing a similar situation with your care provider(s)? What has been your experience? Let us know!
