Here, as of 2008, were the 10 largest systems in revenue size:
1. Veterans Administration Hospitals, $40.7 billion
2. Hospital Corporation of America, $28.4 billion
3. Ascension Health, $12.7 billion
4. Community Health, $10.8 billion
5. New York Presbyterian, $8.4 billion
6. Tenet Health, $8.3 billion
7. Catholic Health Initiatives, $7.8 billon
8. Catholic Health West, $7.6 billion
9. Sutter Health, $6.9 billion
10. Mayo, $6.1 billion
What strikes me about this list are that such giant systems like Kaiser, the Cleveland Clinic, Johns Hopkins, Duke, and Health Partners in Boston don’t even appear, and the large number of Catholic multi-system chains. The revenues of multi-hospital systems has undoubtedly grown since 2008. In 2011, hospital mergers and acquisitions hit an all time high.
More than half of all hospital admissions , 60% to be precise, occur in the 200 largest hospital systems, hospitals now own more than half of physician practices, and large hospital systems are gobbling up rural and smaller
hospitals at an accelerating rate.
Reasons behind the growth are self-evident:
> Market and monopoly power to become dominant preferred providers in geographic regions
> Administrative flexibility in coping with reduced federal reimbursements, trimming duplications, and creating hospital-physician bundled billing organizations
> Need to expand into outpatient markets by acquiring physician practices
> More ability to negotiate higher payer prices, particularly from private insurers
> More capacity to invest in health reform demands for quality, safety and electronic systems
> Enhanced abilities to direct referrals and to build high tech centers for imaging, cancer, heart and orthopedic centers
> Anticipation of influx of 32 million more paying Medicaid recipients in 2014 and 78 million new baby boomer Medicare eligibles over the next 18 years.
Critics worry that consolidation:
> Will create monopolies that will drive up prices and costs for government and
> Will make hospital owners of physician practices the real economic masters of
the health system, rather than government or physicians and their
As Humpty Dumpty said in Through a Looking Glass,“ The question is: which is to be the master, that’s all.” The new question is: In the physician world, will hospital systems, now the dominant physician employer, dictate and direct what physicians can do, rather than physician organizations?
For insight into what a reform-minded government thinks about this and other matters, I will like to quote the words of Ezekiel Emanuel, MD, who was one of President Obama’s principal physician advisors from his perch at the National Institutes of Health before his present physician at the University of Pennsylvania, as cited by David Nash, MD, head of population health at Jefferson Medical College in MedPage today.
“Initiatives launched under the Patient Protection and Affordable Care Act (ACA) of 2010 are key to the solution:
> A former Washington insider, Emanuel believes that unless the Supreme Court does
something completely “wacko,” the U.S. will have universal coverage (with the exception of undocumented persons and refusals).
> Costs will decrease and — with advances in interoperable electronic medical records
(EMRs), comparative effectiveness research, reporting, and medical error reduction — quality will improve.
> Changes in the delivery system will serve as catalysts
Within the next 10 years, Emanuel predicts that:
1.Checklists will be used routinely for intravenous therapies and surgery
2. Electronic medical records, health-related smart phone apps will become the
3. Remote monitoring of metrics such as weight, blood pressure, glucose levels
will facilitate the management of chronic illness.
4. Health insurance as we know it will disappear
Not My Opinion
That is Emanuel’s opinion. I believe the Supreme Court may indeed do something
“wacko,” like strike down Obamacare.
Emanuel may be right on counts 2 and 3, but not on 1 and 4.
I do not believe you can replace clinical judgments and patient desires with checklists. I do not believe Accountable Care Organizations, which are essentially government-directed consolidation of hospitals and physicians into organizations offering bundled bills, will reduce costs, nor do I believe they will replace health insurances companies. . That is “top-down” centralized command and control government thinking, and not “bottom-up” behavior in the real world.