
Hospitals mergers do not improve quality: study - vo2maxer
https://www.wsj.com/articles/hospitals-merged-quality-didnt-improve-11577916000
======
Ensorceled
I'm always fascinated when health care discussions start up on HN; watching
Americans argue amongst themselves about single-payer or nationalized health
care systems as if those systems are dangerous thought experiments are
mesmerizing.

No matter how many people say "but a well regulated mandatory multi-payer type
of system is working in Germany" or "nationalized medicine is working in
Canada" it's all just ignored and the argument continues anew.

~~~
coldtea
> _No matter how many people say "but a well regulated mandatory multi-payer
> type of system is working in Germany" or "nationalized medicine is working
> in Canada" it's all just ignored and the argument continues anew._

I don't think their problem (at least of one side of the debate) is whether it
will work or not.

Their issue is a moral one, whether they should ever pay into a health care
pool for the benefit of other people.

Those that think they can manage on their own don't see why that should
happen. And as a protestant inspired culture that took it even further than
the original protestants, they find this appalling.

They'd rather see people die in the streets and step over them on the way to
brunch, than have themselves, hardworking "good" persons that they are,
contribute for the health of the poor and the "losers". Even more so if it's
mandatory. Charity from their magnanimous heart, they can consider.

~~~
SamuelAdams
This mindset does not make sense to me. People already pay for local schools
(K-12), even if they have no children. They already pay for a local library,
even if they never use it. They pay for a local fire department, even if their
house never burns down. They pay for a local police station, even if they are
never the victim of a crime.

People pay for services that benefit others all the time - why should health
be any different?

~~~
quadrifoliate
> People already pay for local schools (K-12), even if they have no children.

Very rarely. Good schools attract paying parents with large families, leading
to a self-reinforcing effect and affecting property values so much that it's
one of the search facets on property sites like Zillow. So really they pay for
_their_ children, usually.

> They already pay for a local library, even if they never use it.

This is a relic of when people _did_ use libraries more. A lot of library
systems are dying out with the excuse of "but we prefer Kindles".

> They pay for a local fire department, even if their house never burns down.
> They pay for a local police station, even if they are never the victim of a
> crime.

They do this more out of fear of avoiding viscerally life-threatening
consequences. Somehow healthcare has assumed the status of _not_ such a thing
in the States.

\-----------

For what it's worth, I am strongly opposed to these viewpoints, but just
stating that there is not as much self-contradiction there as you think.

~~~
boardwaalk
What do you mean people “very rarely” pay for local schools? I pay over 50% of
my local property taxes into the school district here. It’s roughly that much
all over the city and all over any big city in my state; you can’t escape it.
And it was about $2800 out of my pocket last year.

And if you’re not paying this directly, it’s probably because you rent (and
you’re getting passed on the cost) or it’s hidden in income taxes.

~~~
quadrifoliate
> What do you mean people “very rarely” pay for local schools?

I guess a nuanced version of what I mean is – they very rarely pay _a lot_ for
schools if they don't have children. Put another way, they _do_ pay through
the nose for schools if they _do_ have children, which it sounds like you are
doing.

Of course there are exceptions to this. Maybe you live in a district with
great schools and have no children, in which case you are paying for a great
school with no direct way you can take advantage of the benefits. My point was
that this situation is relatively rare; perhaps it wasn't expressed too well.

------
0xcde4c3db
Has there _literally ever_ been a case where a merger actually improved things
for customers to the extent suggested by the merging companies? I certainly
can't think of one.

~~~
gretch
A lot of people think that tmobile and metro PCS merger really benefited the
mobile carrier industry.

While there were more companies before the merger, verizon and at&t were
dominating that a long tail of small companies was not true competition.

When tmobile merged, it started to add a true 3rd competitor to the scene and
they were the first to do a lot of stuff with unlimited data. Many people
attribute verizon and at&t following suit to their initial move.

Of course this is speculation as no one can prove casual linkage between these
events, but it seems pretty plausible.

~~~
lotsofpulp
I think sprint and T-Mobile merging would help create a real competitor to ATT
and Verizon too. It’s just the nature of mobile networks that bigger is
better.

~~~
dangus
I disagree here, with the disclaimer that I don’t have an incredible knowledge
of this industry so my details could be inaccurate. I’m just an armchair
quarterback.

Sure, Sprint is a dead carrier waking, but T-Mobile is _already_ a competitor
to Verizon and AT&T.

T-Mobile doesn’t need Sprint to compete with the other two at this point. They
have the spectrum. They also have a 5G network rollout out with the lowest
frequencies, which means they’ll actually have a coverage advantage.

Back to Sprint, they essentially can’t afford to build out 5G. But for
consumers, they’re the cheapest option by far, especially when you consider
their MVNOs like Boost Mobile. They also have a tremendous mess of spectrum
that isn’t a very good situation for device interoperability and availability,
nor is it good for rolling out 5G at all.

In other words, Sprint needs T-Mobile, but T-Mobile doesn’t need Sprint.

If Sprint cut costs and declared that they are the cheap, forever on 4G
network, that would benefit price-sensitive consumers. Sprint’s competitive
advantage would be that it doesn’t have to spend a lot of money on bothering
to upgrade anything, or the marketing budgets that Verizon and the rest spend
(I’d love to know how much of our monthly bill ends up on TV), and that their
4G network is good enough if you mostly care about price.

In my view this is the alternative that the corporations won’t even suggest to
the public because it’s not as profitable. The people who own Sprint maximize
their investment returns by selling to T-Mobile.

Sprint going bankrupt or being sold in pieces or in whole may even benefit the
consumer more than Sprint being absorbed by T-Mobile, but the big three are
never going to admit that.

Finally, what’s happening here is that you are unintentionally parroting
T-Mobile’s own PR and lobbying efforts. T-Mobile put out news stories and
press releases describing this exact scenario and how it benefits the
consumer. They claim that they will truly do 5G right if they own Sprint, but
I think they just want Sprint’s customers to be tacked on to their own.

~~~
lotsofpulp
> T-Mobile is already a competitor to Verizon and AT&T.

How come T-Mobile is consistently cheaper than ATT and Verizon? How come
Verizon is the most expensive?

If the networks were the same, why would people opt to pay Verizon more? As
far as I know, for coverage, Verizon > ATT > T-Mobile. It’s mostly a function
of more towers, and I presume T-Mobile has the fewest.

------
Heyso
Hospitals, healthcare, should not be a business. If money is the end goal,
cheap + efficient medicine will be thrown away, it might not even be
profitable ! A curse for a businessman.

~~~
lotsofpulp
There aren’t sufficient amount of people willing to do the highly undesirable
work of caring for sick, contagious, handicapped, possibly dangerous people
without money as the end goal.

~~~
markvdb
Don't underestimate how many people find meaning in care work, whether it's
financially very well compensated or not so much. Look at places where
healthcare is less subject to market forces, like substantial parts of the EU.
You might get positively surprised.

And good compensation for health professionals can happen in a non-profit
context too.

~~~
lotsofpulp
How can I be underestimating when it's a fact that there is a shortage of
nurses, and hence nurse unions have decent sway.

~~~
markvdb
Medical professionals will notice if healthcare moves somewhat away from the
market. They will feel safer investing energy without expecting market based
financial compensation.

Compare to an free or open source project. A project that pays some
contributors, but not others is a rather unhealthy situation. Such a project
would have more difficulties attracting and retaining developers.

Don't underestimate what people will do for other than financial compensation,
given suitable conditions.

------
tehjoker
There is one case where quality might improve and definitely cost: nationalize
them all into a single system.

~~~
seibelj
Many on the left despise mergers and consolidation, and anything that has a
hint of monopoly power. _Except when it comes to government, education, and
healthcare!_ Doesn’t a single centralized monopoly providing everyone’s
healthcare seem like a bad idea? Why is it so bad in business and so good for
health?

~~~
karlshea
> Doesn’t a single centralized monopoly providing everyone’s healthcare seem
> like a bad idea? Why is it so bad in business and so good for health?

Because health shouldn't be run like a business, just like the fire department
shouldn't be run like a business. The only metrics that should matter are
patient outcomes and cost.

~~~
maximente
sorry but how then should the fire department be run? both seem resource
constrained at both the macro and micro level.

my understanding is that at a macro level firefighters routinely "trade"
regions for sake of better defending bigger or more important regions. it will
have to be the same for health care: not everyone can afford a legion of 24/7
ICU nurses and ER physicians on standby when the end comes, even if .gov is
footing the bill.

IIRC dems got killed for "death panels" when ACA was getting played up. there
will always be death panels - someone who decides whether or not an additional
dollar is warranted for any particular individual - so what inputs should we
use to make those decisions in your opinion?

~~~
lsiebert
the so called "death panels" were Politfact's Lie of the Uear.

They were AARP supported voluntary sessions, paid for by Medicare, where
people could discuss stuff like living wills and other end of life issues.
[https://www.politifact.com/truth-o-
meter/article/2009/dec/18...](https://www.politifact.com/truth-o-
meter/article/2009/dec/18/politifact-lie-year-death-panels/)

~~~
lsiebert
/Uear/Year/

------
qrbLPHiKpiux
The only thing hospital mergers do in my area is to consolidate the billing
and turn it into an absolute non forgiving nickel-and-dime machine.

~~~
hermitdev
Id wish for consolidated billing. Every time I end up in the hospital (which
is about twice a year), I seem to end up with bills from 5-6 different
providers. 1 from the hospital itself, a separate one from ER services,
another from the pharmacy, one each from the specialists I see, another for
lab work and yet another from radiology/imaging.

This bifurcation of billing makes an easy trap into falling into dilliquency
because youre inundated with so many bills for the same visit that, even if
you can afford to pay, you're like, "didnt I already pay for this?"

Seriously, the hospital near me seems to be a racket for Bill collectors. It
seems no one is employed by the hospital proper and that theyre effectively
all subcontractors that submit their bills directly to the end client, despite
never being notified of that.

I cannot imagine a process like this where I hire a contractor to build a
house at X rate, and they agree, and then all of the subcontractors bill me
directly outside of the initial agreement. Maybe not the best analogy...

I fucking hate medical billing practices.

(I'm in the US)

~~~
jachee
In your house building analogy, you've got a leg up on the medicine-industrial
complex by being able to get a value for X up-front.

~~~
zoomablemind
The X rate is at least the negotiated professional rate, not necessarily the
total bill.

Too often hospital care involves out-of-network doctors, that will bill
directly as they may not have contract with your insurance. Knowing who'll be
on duty ahead of time is not always if at all possible.

------
jayd16
I can't read the article. Does it get into whether the hospitals actually
merged process in any useful way? I worked at Kaiser when they were attempting
to get their hospitals to share medical records (through SOAP). It taught just
how home spun every hospitals IT is. Frankly, I'm a little skeptical much
progress could have been made as a result of a recent merger.

------
neonate
[http://archive.md/5ZM9V](http://archive.md/5ZM9V)

------
Ice_cream_suit
Mergers are about improving profits, not improving quality.

~~~
rejschaap
For mergers the best case scenario is probably quality remaining at the same
level.

------
Mountain_Skies
Consolidation of IT systems should make them easier to protect but in practice
it seems like the net result is any IT problem ends up harming multiple
hospitals instead of just one. When the same chain owns multiple hospitals in
a single market, all of them having IT problems at the same time is dangerous
as the others can't pick up the slack.

~~~
jcims
IT consolidation only happens when it is prioritized, and in many cases you
end up with some hybrid system of bastardized mapping/integration tiers rather
than a pristine single environment. Healthcare IT also has the challenge of
ridiculous amounts of highly specialized and largely turnkey systems, interop
with other hospital and research organizations and of course the ever-present
regulatory requirements that must be maintained throughout.

Didn't read the article but the headline is absolutely not a surprise.

------
bitxbit
Unintended consequences of PPACA made the system significantly worse. They let
multiple industries consolidate using PPACA as an excuse. Yet no one will talk
about it for political reasons. This happened across the board not just among
hospitals. I am surprised UNH didn’t start buying out biotech companies to
make drugs exclusive to their plans.

------
RaceWon
Quality? The peeps who are already make big money running hospital
corporations are mainly interested in making more money. Where I work patients
are actually to as customers in some interoffice emails...

Quality :)

------
known
I think compulsory
[https://en.wikipedia.org/wiki/Second_opinion](https://en.wikipedia.org/wiki/Second_opinion)
can improve quality

------
huijzer
Nor do business mergers in general. The benefit of mergers is that bigger
companies have bigger benefits for top executives. For example, higher status,
bigger paycheck and better car for the CEO.

------
amelius
But what happens to cost?

~~~
paulddraper
Cost to the insurance/patient skyrockets because the hospital has better
leverage.

This is the real reason for rising healthcare costs.

Pro tip: go to a smaller clinic or hospital and save $$

~~~
nradov
Payers (insurers) are increasingly acquiring provider organizations as a cost
control measure. The industry is gradually converging on the Kaiser Permanente
business model.

~~~
paulddraper
In Utah, the reverse is happening where Intermountain Healthcare (provider)
started Selecthealth (payer).

------
teekert
I recently realized that hospitals in the US are for profit. So probably, the
mergers do increase returns for investors? Which was probably the goal of the
merger anyway.

~~~
chapium
Reduce management overhead and align merged facilities with cookie cutter
standards. Ironically a lot of merged systems keep their previous IT
infrastructure, so it becomes a big interfacing job rather than
standardization.

------
killjoywashere
Anybody have full text or a link to the original?

~~~
paulddraper
[http://archive.md/5ZM9V](http://archive.md/5ZM9V)

~~~
killjoywashere
Thanks, that the study was published in the New England Journal was enough to
find the actual study:
[https://www.nejm.org/doi/full/10.1056/NEJMsa1901383](https://www.nejm.org/doi/full/10.1056/NEJMsa1901383)

------
modmans2nd
I wonder if they separate the for profit and non-profit mergers what they
would find.

For profit (in my exe) has always been lower quality.

------
neilwilson
The reason you want smaller entities in private healthcare is that is reduces
the size and impact of bankruptcy risk. Same reason you want smaller banks.

If you want competition to work you have to have sufficient excess capacity in
the system to allow entities to fail and fail fast.

Not so much a case of big enough to cope, but small enough not to matter that
much in the grand scheme of things.

That ought to be the rule of thumb for any competition authority - if this new
entity went pop, would we notice?

Capitalism without the threat of bankruptcy is like Catholicism without the
threat of hellfire. It no longer works as a concept.

------
whb07
In before, “This is proof positive free markets don’t work for healthcare”.

Excellent material for those interested, an actual cash only, price listed,
customer facing hospital. Shiver ye comrades for the devil capitalist is and
has been here.

[https://www.econtalk.org/keith-smith-on-free-market-
health-c...](https://www.econtalk.org/keith-smith-on-free-market-health-care/)

~~~
someguydave
Thanks for pointing out reality here. As you can see, it doesn’t go over well
here on HN.

------
petjuh
I can't read the article, it seems to be behind a paywall or something.

~~~
BlameKaneda
[http://archive.md/5ZM9V](http://archive.md/5ZM9V)

