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In this episode, Medical Economics Managing Editor Todd Shryock interviews Joseph Betancourt, MD, president of the Commonwealth Fund, about health care consolidation. Betancourt discusses the significant increase in consolidation over the past 7 to 10 years, driven by the goal of creating efficiencies and improving care. However, he notes that these benefits have not materialized, leading to challenges for patients and providers.

Music Credit: Sketch by High Proof - stock.adobe.com


Consolidation Trends (00:00:55)
Betancourt discusses the increasing trend of consolidation in the healthcare industry over the past 7 to 10 years.
Impact of Consolidation (00:03:10)
Examining the claimed benefits of consolidation, such as improved efficiencies and patient care, and the actual outcomes, including no significant quality improvements and increasing prices.
Survival of Independent Practices (00:05:33)
The challenges faced by independent medical practices in competing with larger consolidated systems and the potential impact on their survival.
Disappointing Results for Disruptors (00:08:00)
The discussion around the underwhelming results of disruptors like Amazon, Walmart, and CVS in the healthcare industry and the potential implications for future consolidation.
Access and Convenience (00:10:10)
The impact of consolidation on access to healthcare services and the efforts made by large systems to improve access and convenience.
Continuity of Care (00:11:50)
The potential impact of consolidation on the doctor-patient relationship and the importance of continuity of care, especially for patients with chronic conditions.
Autonomy and Agency (00:14:06)
The loss of autonomy and agency experienced by physicians in larger consolidated systems, leading to potential unionization movements.
Physician Compensation (00:15:54)
The variability in physician compensation when joining larger entities and the lack of clear trends in this regard.
Administrative Burden (00:16:50)
The discussion on whether joining a larger entity relieves physicians of administrative tasks and the ongoing challenges related to administrative burden in healthcare.
Quality Care for Independent Physicians (00:18:37)
Advice for independent physicians on maintaining and improving quality care for their patients in the current healthcare landscape.
Consolidation Trends (00:19:49)
Discussion on the ongoing trend of healthcare consolidation and its impact on providers and patients.
Unresolved Impact (00:19:54)
Uncertainty around whether healthcare consolidations are delivering the proposed benefits and the challenges faced by providers and patients.

Todd Shryock 0:56
So, I guess, to kind of set the table, can you give me an idea of how consolidation is trending with medical practices? Is the pace increasing? Is it slowing what you know what's going on with the pace of consolidation? Yeah,

Joseph Betancourt 1:11
There's no doubt that, you know, over the last seven to 10 years, we've seen a very large increase in consolidation, generally. I'd say the consolidation that's gotten the most attention is a consolidation of the health system level. And we've had probably, I think about 1,000 of 5,000. Hospitals are now in systems that they've gone into consolidated systems.

Betancourt 1:38
I'd say that the notion behind consolidation, the driving theory behind it, from people who are executing consolidation is that by consolidating, you can create efficiencies, you can make care more effective. It's often said that you can eliminate redundancies that you can improve, improve health information systems, this notion that by consolidating and bringing disparate parts together, and what many claim is a healthcare system that's very fragmented, will be helpful for patients and will be helpful for providers. Many say well, providers would really benefit from having many of the administrative issues that they have to deal with on a onesie twosie basis, kind of taken off their plate and a consolidated system allows for that allows for more seamless patient interactions, better communication among providers, all those things.

Betancourt 2:43
So, I guess I'd say definitely a trend towards consolidation. Definitely, we're seeing it pretty extensively in the healthcare system level. And I would say that the party in charge of monitoring these consolidations, the Federal Trade Commission, really is tasked with the idea of are these consolidations, anti competitive in any places? Or are they creating monopolies in regions? Right. And I think the data has shown that there's only been 13 consolidations that were rejected by the Federal Trade Commission in the last few years, among which independent analysis shows that probably up to 200 could have been, right.

Betancourt 3:30
And so I think you have leaders who are pushing for consolidation, really putting together all the pros that I've suggested. You have the Federal Trade Commission underpowered in its ability, I think, to really look at this carefully and perhaps buying into some of these notions. But, Todd, the the key challenge here is that to date, the data on living up to that potential consolidation is falling short.

Betancourt 3:59
What we are seeing, no doubt, as we see more consolidations is no real improvements in quality. If anything level or decreasing in quality. I would say that we're seeing no doubt increases in prices. I would argue, and this is based on my experience, I think it is becoming increasingly confusing and frustrating for patients to figure out where to go and how to navigate, oftentimes, these consolidate systems, which is almost antithetical to why people are saying consolidation should be put forward in the first place, it's actually become challenging for patients. And then finally, for providers, I think there's been a real loss of agency, if you will, sense of being able to have a voice or feel like you have control in where these big systems and consolidated systems are going. And so this is what we see: more consolidation on the promise of these improvements, the data showing those improvements aren't really being realized, and I would argue patients and providers being stressed in a variety of different ways about where this consolidation is going, and I'll, yeah, so I'll stop there, I could go more into primary care. But I just want to frame that up in a big picture.

Shryock 5:23
So, with all this consolidation, for the practices that have not sold yet, can they survive with all these major players around them?

Betancourt 5:32
That's a really good question, and I think, you know, even in primary care, I would say even those primary care practices that are within these large systems are not realizing the potential, the benefits of the potential that that is being put in front of them. I think largely, even among these large systems and these large consolidated systems, we're seeing that primary care is being undervalued. Primary care is being used as a conduit to largely higher margin services. And we've seen you know, as as a nation, we spend about 4 to 5%, on primary care can compare it to other nations, where that's been, you know, up to 14 to 15%. So I would argue that primary care practices within consolidated systems are challenged and outside exceptionally challenged, because now they are forced to compete with very, very large players. And at the end of the day, they might not be able to compete. So I'd say in both circumstances, the primary care practice is a challenge. And certainly, if you're not part of a system, you know, you're even more challenging. That's why we've seen more and more these practices be willing to sell be willing to join into the systems, because they, you know, I think, largely now we see three out of four physicians are part of either, you know, private equity practice, or a consolidated system or corporate practice, right, three out of four, it's only one out of four physicians still remain independent, I think there might be a place for some more independence in places like rural areas and the like where there's no other show in town. But in many, many areas, I think these these practices that are not part of systems are at risk. And I think that's a challenge, their power, to be able to negotiate, becomes extremely limited. And I think the other aspect of consolidation that we're seeing is that, from a business standpoint, those large consolidated systems get more power when they negotiate with payers. That's why costs go up. The smaller practices don't really have a prayer in that environment.

Shryock 7:40
With these larger entities, not seeing the results that they thought they were going to see. And you know, there's been high profile at you know, Amazon, Walmart, CVS all came with much fanfare, have quickly said, we can't make money here we're out, you know, for the most part, is the shine wearing off? Is that going to maybe slow things down a bit? Or is it just the next person in line thinks, hey, I can do this? And

Betancourt 8:07
That's a fascinating question, yeah, I think, you know, I think it's fascinating, because many, many people over, you know, over our history have said, I got I could solve this. And I think, to your point, these disruptors, non traditional healthcare players have entered healthcare, with the notion that if we bring business principles, to the care of medicine, that you know, that basically, the healthcare system is poorly organized, inefficient, and we can solve that. And I think our incredibly fragmented healthcare system and payer space, has made them quickly realize it's not that easy, you know, and I think Walmart's exit to me is a is is signal not noise. It's signal that it's not as easy to make margin here. It's not as easy to find those efficiencies. And, you know, certainly may not be generating the revenue that they anticipated and some of the other benefits. It's gonna be interesting to see what happens with Amazon. It'd be interesting to see what happens with Aetna and CVS. It's interesting now that CVS is looking for a private equity partner to help support Oak Street. Right. That's, that's another signal to me. That's not That's not noise. And so to your point, I agree. I think this isn't a problem that is easily solved with business principles. And some of these disruptors, I think, you know, the story will unfold, but we're starting to see signal here, that that just isn't something that by bringing business principles, you can be coming in and beating up the inefficiencies that traditional healthcare systems have had.

Betancourt 9:50
I'll end by saying that I think one thing that they've really helped shape the industry to do is focus more on access and convenience. There's no doubt that the large break mortar systems looked at what a, you know, Minute Clinic could do, and how consumers flocked to that convenience. And now many of them are building their urgent care centers and the like to meet that need of convenience. And so they did help, I think shape the industry to be more efficient to be more effective to survive to be more convenient. But I think they haven't been able to create the value that they wanted so far. And so you know, that story is still in play.

Shryock 10:28
Okay. You know, I wanted to ask about if you've seen any impact on access to services, but it sounds like if anything, maybe that's the one area where consolidations actually maybe helped a little bit or no?

Betancourt 10:39
Well, you know, yeah, it's a good point, I think it's an area where, because of those disruptors, the large systems have needed to be more attentive to it. Now, whether they've achieved it, I think they've gotten better. But if you still look at access and affordability today, particularly in primary care, and this is in large part due to the primary care workforce shortage, the fact that less people are going into primary care, that primary care is underpaid, and we're looking for payment reform to really fix some of that this is a major issue on the hill. You know, despite the best efforts of large systems to make themselves more accessible and affordable. I think they're still not nowhere near where they want to be. So there's still big challenges there. But they're a lot more attentive to it, because of the Amazons and the CVSes of the world and the Walmart's because I think they saw some key ingredients there. And they realize if we don't change, we know, we may not be around, they actually might might win, so yep.

Shryock 11:34
What about continuity of care? Has there been any impact on that important, you know, especially in primary care, that doctor patient relationship? Can you still have that old fashioned relationship? Or is that suffering from because of consolidation as well?

Betancourt 11:50
Yeah, Todd that's a great, great question. I mean, I think, putting consolidation aside for a second, I'd say that, you know, what we do see, because of the disrupter disruptors and some generational changes, is that there are, you know, individuals with who don't have chronic conditions and who have low acuity issues that emerge: a cold, sore throat, urinary tract infection; particularly generationally, I think, voted with their feet and will sacrifice a relationship for access and convenience.

Betancourt 12:26
Individuals with chronic disease, that relationship really, really matters. And so I think what we're seeing, Todd, is an evolution, such that we might see sub-segmentation based on the patient's needs, that will prioritize or deprioritize the importance of that relationship and the traditional primary care doctor, right.

Betancourt 12:50
I take care of a lot of, you know, 18- 19-year-olds, I see them once a year, you know, if they have a cold, and I'm not available, it makes sense for them to go see somebody else, and they'd probably prefer it if they can't see me for two weeks. I think we're going to that's probably going to end up being more formalized down the road.

Betancourt 13:07
Does consolidation impact this? I'd say, you know, maybe not so much. I don't think that there's a clear impact between consolidation and the primary care relationship as long as those large systems invest in primary care. So, if you're a large consolidated system, and you don't invest in primary care, then yeah, that you know, those relationships are going to are going to go that you know, that stickiness and the importance of the primary care relationship is gonna go away. But if you're a big system, and you really prioritize primary care, I believe you could maintain that continuity, it's a matter less of consolidation and more about prioritization. And I say today that consolidated large systems, for a lot of different reasons haven't particularly prioritize primary care,

Shryock 13:55
For physician physicians who end up in these larger systems, do they sacrifice any of their autonomy? Do they have the same decision-making power that they had before? How does that work?

Betancourt 14:06
Yeah, Todd, I think, you know, many, enter into these systems under the guys that that consolidated system will take away a lot of the administrative burden that you have: billing, IT, and the like. But then the trade off ends up being that sense of agency and autonomy and your voice being heard and big decisions around where the system goes. Right? And so I think it does. The impact has been demoralisation, and I think the impact impact has been loss of agency and what is this translating to? This is translating to the burgeoning unionization movement that we're seeing. First, we've seen it most strongly among trainees and residents. But you're starting to hear and you're starting to sniff out and you're starting to see Allina in Minnesota, we here at Mass General Brigham Salem Hospital a group of 60-70 some odd doctors unionizing, you're starting to see more of that.

Betancourt 14:10
So, the way that this is playing out, and we might see an increase in it, is doctors starting to say, 'we need to unify our voices to regain our agency and empower to do right by our patients.' Because I think there is a sense of, with these consolidations, comes a corporatization of medicine. That's less than ideal for patients and providers.

Shryock 15:36
Outside of medicine, usually working for a large corporation, as opposed to like an independent family business. The pay and benefits are better. Is that true for physicians as well? Are they at least getting better pay and benefits when they go the corporate route as opposed to remaining independent?

Betancourt 15:54
That's a good question. I think it's very variable dependent on specialty. Some specialties do better on their own some some do better as parts of systems. It depends on location and market. I don't think there's a particular trend to say that, you know, I don't know, I don't know of any data. I haven't seen any studies that would say, you know, physicians in consolidated systems get paid more or less? I think it's variable. I think it depends on the who, the what, the where, the system. Yeah, there's a lot of variables there. I don't think that question has been answered yet.

Shryock 16:29
You've mentioned a few times that trying to escape the administrative burden is one of the reasons why you would join a larger entity, has that proven true that, at the very least, the doctors have less administrative tasks to deal with?

Betancourt 16:48
Ah, look, I think we definitely, you know, having just individual practices does have implications for quality of care. Right. I think people working together can improve quality, there's no doubt. So I just set that aside here. But, you know, to your question, I think individuals who enter into these systems probably do find some economies of scale. Perhaps they are relieved of some administrative responsibilities related to quality or billing and the like, those are taken up as responsibilities system, which is, I think, a benefit. Two things I'd say: at what expense, right? And the second is, there's still a lot of administrative burden that comes with just care in general.

Betancourt 17:47
So, while you enter a consolidated system, and it might decrease some of the administrative burden, the practice of medicine is leading to just generally more administrative burden with the electronic health records. So along what I'm saying Todd, if I'm in a consolidated system, or I'm independent, and I'm on Epic, and I have inbasket, my in basket's still gonna have 90 messages. You know, I think the systems are trying to address that now. So for example, at my practice they're going to have nurse practitioners reviewing my in basket. So it may be that consolidated systems could throw more resources at decreasing administrative burden around the day-to-day, and I think they're trying to so we'll see how that plays out. But again, I think it might relieve some, there's some that it hasn't relieved yet, and it's trying to pay more attention to how it can relieve them. And we'll see how that plays out with time.

Shryock 18:38
So if I'm an independent physician, and I care about quality care for my patients, you know, what would you tell me in today's world? How, you know, what do I do?

Betancourt 18:50
Yeah, I mean, I think over the years, we've seen small practices, be able to, you know, come together as part of collaboratives, data share, be part of Quality Collaboratives through a variety of different national players. So, you know, we quality really matters. And I think when you're running a practice, you know, oftentimes your data capability abilities to monitor quality, the amount of time that you could spend and in kind of developing registries to make sure all your patients are at, you know, target around their cholesterol, there are a lot of systems related issues that not because of lack of caring, but because the lack of resources and time you might not be able to invest. And that's been some of the challenge of smaller independent practices, as practices have grown, they've been able to add those capacities in. But I think independent practices, certainly there are things they can do together and with payers and with other partners that can help them focus on these things which are of critical importance.

Shryock 19:49
Any other thoughts on consolidation that we haven't talked about?

Betancourt 19:54
No, I mean, I think I'd end by saying that, you know, we definitely have a trend towards consolidation. I think the jury's definitely still out on on the, you know, are these consolidations yielding the benefits they propose? While at the same time, we're seeing some of the challenges to providers and patients. So this is an unfolding story. But we're in the midst of a trend and we'll see, you know, kind of where it goes.

Podcasts

Joseph Betancourt, MD, president of the Commonwealth Fund, sits down with Medical Economics to discuss health care consolidation.

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What questions should a physician or administrator be asking their broker about regarding a medical professional liability (MPL) carrier?

The two things that would always be on my list are financial strength and geographic reach. Financial strength is probably the most important, because when you’re buying an insurance policy, you’re essentially buying a promise that the insurance company is going to be there to pay your claim if and when you report one. A carrier’s AM Best rating will indicate financial strength through the assignment of a letter ranging from A to D, and then they’ll add some plus or minus signs after that to further refine that financial rating. A++ is for the very strongest carriers while D is for the weakest.

Geographic reach is important because the practice of medicine today is not the practice of medicine as it was in the 1960s or 1970s. Economic realities of practicing medicine today really do reinforce consolidation pressures, and we see a ton of it within the medical professional liability industry, as practices in one state acquire practices in another state, or as physician groups in one location look to provide health care services to patients in another location. Having an MPL carrier that can ensure the totality of that practice is, I think, very important. If you’re a practice administrator or a physician leader, you’re not going to want to deal with multiple medical liability carriers. I think you want to be insured by a company that you can grow with as your practice grows.

: In 2019 or 2020, we started to hear the medical professional liability market characterized as a “hard market.” What does that mean, and does it continue to be true?

Competition has been one of the leading factors relative to whether the conditions are soft or hard. Over the last several years, the market has become very competitive. In the past 10 years, the rate competition in particular, coupled with a market where the overall base of insured physicians has significantly declined due to consolidation, there are simply fewer physicians to insure, and corresponding premiums have declined within the MPL segment.

I think it’s fair to say that from 2012 to 2019 the MPL market conditions were quite soft. During this period, as companies competed heavily, with aggressive rates and reductions in premium. From a financial standpoint based on earned premium less expenses and losses most companies reported combined ratios well over 100% and continued underwriting losses within the segment. As the underwriting losses continued, many companies were still able to report an operating profit typically by applying investment income and reserve redundancy. During this timeframe, AM Best had placed a negative outlook on the MPL Sector.

In 2019 and 2020, we started to see indications that the MPL sector was stabilizing somewhat, with less aggressive pricing. Most companies focused on improved rates and risk selection aiming toward achieving underwriting profitability and not relying on reserve redundancy and investment income to obtain an operating profit. This led to discussions that characterized the market as moving to a hard market. However, I would not characterize the market as hard, but rather, it has been hardening. I would consider the hospital professional liability (HPL) market of having gone through a definite hard market, but overall we’re seeing a more stable MPL sector, and that’s a good thing. In 2023, AM Best upgraded the outlook on the MPL sector from negative to stable, noting both positive operational changes but also citing several remaining challenges for the industry.

: Many independent physicians and larger groups or clinics have been acquired by hospital systems and private equity groups. What are some of the pros and cons of this change within the market?

It has changed the landscape of medical malpractice, independent physician practices, and hospital systems. Recent estimates reflect that approximately 75% of physicians nationally are now employed either mostly either by hospitals or private equity firms. As to the pros, there are obviously financial benefits for the groups that are acquired related to the sale. Being acquired potentially transfers a lot of the administration and management of practice onto the health care system. Many physicians see the opportunity to have more flexibility and family time with set schedules.

Physicians that are part of a hospital system, the alignment of interest is certainly there. Both are focused on providing the best patient care, treatments and medical advances.

With private equity acquisitions, similar to hospitals, there’s still an alignment of interest in providing the best health care possible and build upon the overall group practice but it’s a little bit different. Hospitals are there to serve the public, while private equity firms, by definition, are there to build upon revenue and profit. That’s not a negative thing — hospitals need to make a profit as well.

There are certainly cons relative to the many acquisitions over the year. Basically, many times it’s just difficult for these physicians to get used to the new process. They need to transition their current patients to the acquirer, go through a whole network of communications and such, and this can sometimes become a difficult task toward adjusting to their new environment. Further there have been potential problems or areas of disagreement, such as contract disputes, expense reductions, revenue increases or decreases, number of daily patient treatments, longer hours or overall differences as to expectations and responsibilities of both parties.

When you look at the MPL sector now and the HPL sector, there has been many changes and adjustments that both have had to adapt to.Due to the significant consolidations, many MPL companies implemented various diversification programs to supplement their core writings. These included writing in new states, diversified product offering, developing joint alliances with other companies and brokers, along with select changes in investments where appropriate. Hospitals had to adjust to all the issues that come with acquisitions, management of larger and many times more complex systems, as well as restructuring insurance programs and captives. Through it all the industry has gone through at least a 10-year cycle of acquisitions and whereas many challenges remain, the MPL sector has transitioned and adjusted to today’s healthcare marketplace.

: There has been an increase in large verdicts against physicians in recent years. What factors are driving this trend?

The average of the top 50 MPL verdicts for the years 2019 to 2023 has increased from just under $30 million in 2018 to just below $50 million in 2023. What’s behind this? Really good plaintiff’s attorneys are experts in being able to channel a jury’s anger and use that to the benefit of the plaintiffs. Another strategy that plaintiff’s attorneys use is what we call anchoring, and that’s basically where a plaintiff puts out a truly exorbitant value on a case, essentially to get the jury or the mediator anchored in some manner such that even if that number is cut in half, it’s still an absolutely crazy figure.

On the risk management side, a significant key would be to have an even quicker assessment of claims from the moment they’re reported in order to identify a successful claim strategy. One thing that claims adjustors have always said to me is that bad claims rarely get better with age, so they need to be settled faster when the underlying facts of the case suggests that they’re a loser. The last risk management strategy identify resides in defense counsel quality. Sometimes insurance carriers will try to rein in costs in areas they can control, and in the realm of claims, that tends to be legal fees associated with defending malpractice claims. We may save some money in our legal expenditures, but we give it all back and then some on the indemnity side. There are subtle issues that can turn a claim from a defense verdict into a plaintiff’s verdict, or that can take a case that might have resulted in a $5 million verdict to a $20 million verdict.

Two experts discuss how emerging trends in health care — market conditions, consolidation, the physician shortage and more — are impacting physician liability risks.

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