Mergers and Medicaid Expansion

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In a fast-paced Kidney Week 2018 session titled “Reshaping Relationships and Transforming Care Delivery,” Janis M. Orlowski, MD, MACP, chief health care officer of the Association of American Medical Colleges (AAMC), captured the dynamic environment of healthcare in the United States when she led the session with “Consolidation: Friend or Foe?”—the Christopher R. Blagg, MD, Lectureship in Renal Disease and Public Policy.

Orlowski captured the situation with a comparison of the 2008 merger of Mercy Hospital of Pittsburgh, a 160-year-old institution with 428 beds, with the University of Pittsburgh Medical Center, compared with the recent signed letter of intent to merge Baylor Scott & White Health and Memorial Herman, which had, respectively, 2017 operating revenues of $9.1 billion and $5.06 billion. The combined enterprise will have 68 hospital campuses, more than 1100 care delivery sites, about 14,000 independent and academic physicians, two health plans, and approximately 10 million patient encounters annually.

The year 2018 also saw the completion of the merger between Downers Grove–based Advocate Health Care and Wisconsin’s Aurora Health Care, creating the 10th-largest not-for-profit hospital system in the country. The new combined system, called Advocate Aurora Health, has 27 hospitals, 70,000 employees, and about $11 billion in annual revenue. The merged system will keep dual headquarters in Illinois and Wisconsin. The $69 billion merger of CVS with Aetna should also be considered in this context.

Rural consequences

Some of the same factors driving these megamergers, along with the consequences of these types of mergers, have led to the closure of 80 rural hospitals since January 2010 and of 122 rural hospitals since January 2005.

Detailing the AAMC research in the “Future of Academic Medicines Series,” Orlowski described three goals of the research as follows:

  • • How academic medicine is responding to a climate of increasing interinstitutional affiliation and system formation and growth,

  • • How strategies designed to create thriving and sustainable clinical enterprises affect academic medicine’s clinical, educational, and research missions and what options can best assure the sustainability of all of these missions, and

  • • How academic medicine can bring value to nonacademic system partners.

The AAMC research pointed to several major factors driving trends:

  • • Proactive strategic vision,

  • • Market share,

  • • Population health, and

  • • Financial improvement and access to capital.

For market share, “the willingness to consider mergers, acquisition, and/or partnership activity may reflect a strategic plan by a teaching hospital to assemble a larger population base, cover a specific geographic area, achieve ‘scale,’ and reach a certain market share and/or target revenue,” Orlowski said. She further noted that “there is a growing discussion as to whether benefits from merger, acquisition, and partnership (MAP) transactions can be attributed to ‘consolidation’ or ‘scale’ itself or whether the true variable associated with unlocking these benefits is ‘integration’—particularly clinical integration.” She also noted that whereas there is great potential for tackling the challenges of population health in these trends, it is also time for strong leadership on population health.

Some interesting factors in the movement to consolidation are within Medicare and Medicaid. Medicaid’s platform has grown significantly in recent years, and the 2018 midterm elections mean that Idaho, Nebraska, and Utah will be the next three states to join Medicaid expansion. Medicare has seen some interesting changes as well, including the Medicare Shared Savings Program and accountable care organizations, which have grown from $316 million in payments in 2013 to $701 million in 2016, although many are waiting to see what effect the efforts of the Centers for Medicare & Medicaid Services to push these organizations into two-sided risk models will have. At the same time, Medicare private health plan enrollment grew to over 19 million beneficiaries, or 33% of all Medicare beneficiaries in 2017—up from a low of 5.3 million beneficiaries and 13% of all Medicare beneficiaries in 2004—based on a Medicare population of 56.9 million individuals.

Although in 2017, for the first time, the majority of first-year medical school matriculants were women, in nephrology there are still lags. Among active physicians, 28% of nephrologists are women, whereas 35% of physicians are female among all specialties. Among nephrology residents and fellows, 33% are female, whereas across all specialties, 46% are women. When all specialties are considered, 44% of physicians are age 55 or older, but in nephrology the corresponding figure is only 36%. Also, among the 44 largest specialties, the number of active physicians grew 9% overall, but in nephrology, it grew 19%.

Orlowski concluded that consolidation is not a trend—it’s here now—and population health is moving in the direction of accountable care organizations. On the question of “economies of scale,” she thinks the jury is still out.

Medicaid expansion and end stage renal disease

Amal Trivedi, MD, MPH, associate professor of health services, policy and practice, Brown School of Public Health, publicly released his study “The Affordable Care Act, Medicaid Expansion, and End-Stage Renal Disease” concurrently during his talk at the session and with the Journal of the American Medical Association nationally. Before the Affordable Care Act (ACA), one-fifth of nonelderly adults were uninsured at the time they began dialysis.

Trivedi presented that “among the broader population, there is an emerging body of evidence on the effects of Medicaid expansion:

  • • Gains in coverage,

  • • Improved access to care,

  • • Increased use of preventive services, and

  • • Better self-rated health.

The study aimed to measure the impact of ACA’s Medicaid expansion on these factors:

  • • Insurance coverage at time of dialysis initiation,

  • • Predialysis nephrology care, and

  • • 1-year mortality for nonelderly patients with ESRD who begin dialysis.

The study used a quasiexperimental difference-in-differences analysis to examine the change in outcomes among new dialysis patients in Medicaid expansion states compared with nonexpansion states. It also included all patients in the United States aged 19 to 64 who began dialysis from the beginning of 2011 through the end of March 2017, excluding patients with Medicare coverage (including duals) and those with Veterans Administration (VA) coverage, inasmuch as the ACA coverage expansions would not apply to them, although they were included in a sensitivity analysis. This resulted in an analytic sample of over 236,000 patients.

Our primary outcome was all-cause mortality over the 1-year period that began with the 91st day after dialysis initiation,” Trevidi said. “We used this definition of mortality because deaths among incident dialysis patients are not reliably reported within the first 90 days following dialysis initiation (this follows the United States Renal Data System approach). Additionally, only patients who initiated dialysis before January 1, 2016, were included for the mortality outcome to allow for follow-up (180,044 patients).”

The study also examined insurance coverage at the time of dialysis initiation, focusing on Medicaid coverage and being uninsured. It then looked at receipt of predialysis nephrology care. First, the study examined whether the patient had received care from a nephrologist before beginning dialysis and whether the patient had a fistula or graft during their first treatment session. The two nephrology care measures are tracked as part of the Healthy People 2020 goals for chronic kidney disease. The study used both statistical analyses and sensitivity analyses.

Figure 1 shows unadjusted 1-year mortality for patients beginning dialysis. Before expansion, mortality rates were nearly identical in expansion states (dashed black line) and nonexpansion states (solid red line). After expansion, the mortality rate in non-expansion states remained the same, but the mortality rate in expansion states declined after Medicaid expansion was enacted.

Figure 1.
Figure 1.

One-year mortality for patients starting dialysis under Medicaid expansion

Citation: Kidney News 11, 1

Trivedi concluded, “To sum up, the ACA’s Medicaid expansion was associated with improved insurance coverage, access to care, and survival among nonelderly ESRD patients initiating dialysis. This supports the idea that the health effects of insurance coverage are likely greatest for patients with severe health conditions.”

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