Abstract
Mergers and acquisitions among health care institutions are increasingly common, and dialysis markets have undergone several decades of mergers and acquisitions. To examine the outcomes of hemodialysis facility acquisitions independent of associated changes in market competition resulting from acquisitions. Cohort study using difference-in-differences (DID) analyses to compare changes in health outcomes over time among in-center US dialysis facilities that were acquired by a hemodialysis chain with facilities located nearby but not acquired. Multivariable Cox proportional hazards regression models and negative binomial models with predicted marginal effects were developed to examine health outcomes, controlling for patient, facility, and geographic characteristics. All facility ownership types were examined together and stratified analyses were conducted of facilities that were independently owned and chain owned prior to acquisitions. The study was conducted from January 2001 to September 2015; 174 905 patients starting in-center dialysis in the 3 years before and following dialysis facility acquisitions were included. Data were analyzed from March 2017 to December 2018. Acquisition by a hemodialysis chain. Twelve-month hazard of death and hospital days per patient-year were the primary outcomes. Of the 174 905 patients included in the study, 79 705 were women (45.6%), 24 409 (14.0%) were of Hispanic ethnicity, 61 815 (35.3%) were black, 105 272 (60.2%) were white, and 1247 (0.7%) were Native American. Mean (SD) age was 65 (15) years. Before acquisitions, adjusted mortality and hospitalization rates were 10% (95% CI, -16% to -5%) and 2.9 days per patient-year (95% CI, -3.8 to -2.0) lower, respectively, at independently owned facilities that were acquired compared with those that were not acquired, while hospitalization rates were 0.7 days (95% CI, -1.2 to -2.0) lower at chain-owned facilities that were acquired compared with those that were not acquired. In stratified analyses of independently owned facilities, mortality decreases were smaller at acquired (-8.4%; 95% CI, -14% to -25%) vs nonacquired (-20.3%; 95% CI, -25.8% to -14.3%) facilities (DID P < .001). Similarly, hospitalization rates did not change at acquired facilities and decreased by 2.6 days per patient-year (95% CI, -3.6 to -1.7 days) at nonacquired facilities (DID P < .001). Acquisitions were not associated with changes in health outcomes at chain-owned facilities. Slower reductions in mortality and hospitalization rates at independently owned facilities contributed to significant differences in hospitalizations (-2.0 days; 95% CI, -2.5 to -1.6, at nonacquired vs 0.9 days; 95% CI, -1.3 to -0.5, at acquired facilities; DID, P < .001) across all ownership types but not mortality (DID, P = .28) with regard to acquisitions. Acquisition of independently owned dialysis facilities by larger dialysis organizations was associated with slower decreases in mortality and hospitalization rates, as nonacquired facilities appeared to experience more rapid improvements in outcomes over time.
Highlights
In 1991, a report by the Institute of Medicine on the quality of US dialysis care called for monitoring the consequences of a changing mix of dialysis facilities.[1]
Information about large dialysis facility chain ownership came from annual facility surveys, and ownership by smaller chains and independent facilities came from Centers for Medicare & Medicaid Services (CMS) Dialysis Facility Compare
Previous studies have found that health care clinicians may respond to nearby competitive changes in local markets.[33,34]. This competitive pressure or spillover of quality-enhancing practices from acquiring chains to nearby facilities could have led nearby nonacquired facilities to improve care delivery following chain acquisitions. When we examined this possibility in an additional analysis, we found that the magnitudes of estimated acquisition outcomes were smaller when comparing acquired facilities with nonacquired facilities that were not in the same hospital service areas (HSAs), which is consistent with possible competitive spillover
Summary
Mergers and acquisitions among health care institutions can have varying effects on health care costs and patient health outcomes at acquired organizations. When larger organizations more effectively provide specialized, integrated care and invest in quality improvement, the acquisition of smaller organizations may improve both the efficiency and quality of care delivered.[14,15,16,17,18] In contrast, acquisitions by lower quality organizations could lead to worse health outcomes at the acquired organizations. Apart from the direct consequences of acquisitions, reduced market competition resulting from consolidation may lead to higher prices and, in some instances, lower quality of care.[19] Whether mergers and acquisitions yield net improvements in patient health and health care costs depends on the relative magnitudes of these counterbalancing factors.[20,21]
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