Hospital Consolidation: Reducing access for the poor?

项目摘要 医院并购（M& A）增加了医院市场的集中度。2016年， 大都市统计区被认为是“高度集中的”。5.关于医院并购的大量文献 关注对私人价格和医院成本降低的影响。1，6 -14然而，尽管人们越来越关注 从联邦和州管理机构，2，3，15-17很少有人知道并购如何影响获得保健， 特别是对于低收入医疗补助和无保险的患者，他们最经常遇到访问挑战。 为了提高效率和降低成本，合并医院可能会取消一个服务项目（即， （b）如果在另一家并购医院提供服务，特别是如果该服务 22，23这可能会降低当地提供临床重要服务的能力，反过来， 患者的地理位置。此外，医院MA通常会导致私人报销增加1，24，25。 价格歧视的经济学理论表明，寻求利润最大化的医院可能会减少 为医疗补助和无保险的患者提供护理。然而，交叉补贴理论表明， 公立和非营利性医院将利用私人病人增加的利润来进一步补贴 医疗补助和无保险的病人和无利可图的服务符合他们的使命。 建议有必要在广泛的范围内审查与并购有关的准入变化（即，是否 提供服务）和密集边际（即，这项研究将审查并购， 使用2005年至2009年关于医院特征的国家数据， 美国医院协会和医疗保险和医疗补助服务中心沿着与出院水平 来自选定州的医疗保健成本和利用项目州住院患者数据库的数据。首先我会 确定医院是否在并购后减少提供精选的住院和门诊服务， 重点关注由于医疗补助和无保险的高利用率而通常无利可图的服务项目 病人，如物质使用，精神病，产科和创伤服务。接下来，我将估计 医疗补助和无保险的住院病人在并购后发生变化，重点是选择性入院。 虽然法规确保获得紧急护理，但医院没有义务提供医疗补助， 没有保险的病人可选择性地接受住院服务，如膝关节置换和减肥手术。 因此，选择性入院的变化可能最能反映医院限制或扩大护理的努力。基础上 根据这些结果，我将研究并购是否会导致医疗补助和无保险患者向邻近地区转移， 医院，并减少这些病人在区域范围内的总体机会。这项研究涉及一个重要的 通过研究并购对无保险和医疗补助之间不公平获取的影响， 患者，一个跨越几个AHRQ优先人群的群体，包括低收入，种族和 少数民族、妇女、儿童和残疾人。

PROJECT SUMMARY Hospitalmergers and acquisitions (M&As) increase concentration in hospital markets.In 2016, 90% of Metropolitan Statistical Areas were considered “highly concentrated.”5 Much of the literature on hospital M&As focuses on the effects on private prices and hospital cost reductions.1,6–14 However, despite growing concern from federal and state regulatory agencies,2,3,15–17 little is known about how M&As affect access to care, especially for low-income Medicaid and uninsured patients, who most often experience access challenges.18–21 In an effort to improve efficiency and reduce costs, consolidating hospitals may eliminate a service line (i.e., whether a service is offered) at one of the M&A hospitals if it is provided at the other, particularly if the service line is unprofitable.22,23 This could reduce local capacity to provide clinically important services and, in turn, patients' geographic access. In addition, hospital MAs often result in increased private reimbursement.1,24,25 The economic theory of price discrimination suggests that hospitals seeking to maximize profits may reduce provision of care to Medicaid and uninsured patients. However, the theory of cross-subsidization suggests that public and not-for-profit hospitals would instead use increased profits from private patients to further subsidize care of Medicaid and uninsured patients and unprofitable services in line with their mission.26 These theories suggest the need to examine M&A-related access changes on both an extensive margin (i.e., whether a service is provided) and intensive margin (i.e., quantity of services provided).This study will examine M&A- related changes in hospital service provision and access using national data on hospital characteristics from the American Hospital Association and Centers for Medicare & Medicaid Services along with discharge-level data from the Healthcare Cost and Utilization Project State Inpatient Databases for select states. First, I will determine whether hospitals reduce provision of select inpatient and outpatient service lines after a M&A, focusing on service lines that are generally unprofitable due to high utilization by Medicaid and uninsured patients, such as substance use, psychiatric, obstetric, and trauma services. Next, I will estimate the extent to which Medicaid and uninsured inpatient admissions change following a M&A, focusing on elective admissions. While regulations ensure access to emergency care, hospitals are not obligated to provide Medicaid and uninsured patients access to elective inpatient services, such as knee replacements and bariatric surgery. Thus, changes in elective admissions may best reflect hospitals' efforts to limit or expand care. Building on these results, I will look at whether M&As result in shifts of Medicaid and uninsured patients to neighboring hospitals and reduce overall access at the regional scale for these patients. This study addresses an important knowledge gap by examining the impacts of M&As on inequitable access among uninsured and Medicaid patients, a group that spans several AHRQ priority populations, including people with low-incomes, racial and ethnic minorities, women, children, and people with disabilities.