Earlier this month, the Health Policy Institute of Ohio released a newsletter that focused on the percentage of outpatient healthcare facilities in Ohio that are independently owned. Currently only 31.6% of Ohio’s outpatient facilities are independently owned, the sixth lowest rate in the country.
While proponents of this kind of consolidation suggest that it can improve efficiency by simplifying administrative barriers across different levels of healthcare, some research has shown that this has not borne out. Instead, mergers of this kind appear to increase healthcare costs overall while not meaningfully improving patient outcomes.
If this kind of consolidation really is making healthcare more expensive without realizing any gains for patients, then it should be something policymakers care about.
Why consolidation happens
From a theoretical perspective, we expect this kind of consolidation to increase efficiency when there are economies of scale. In other words, if the marginal cost of providing healthcare to an additional patient is sufficiently smaller than the fixed costs of maintaining an independent practice, then it could be better to have fewer providers serving more people.
For example, a large healthcare system can spread administrative costs across more patients. There could also be benefits to having different parts of the healthcare system coordinate with each other, making processes like referrals smoother for patients. These kinds of circumstances create natural monopolies.
The most common example of a natural monopoly is for electricity distribution. It doesn’t make sense to have three companies each build their own set of power lines to every house in a neighborhood. The infrastructure is expensive, and duplicating it would not provide much additional value.
However, natural monopolies are still price setters rather than price takers, and unchecked they will still produce less than socially optimal quantities at a higher than optimal price, particularly for healthcare which we might expect to have an inelastic demand.
How can policy address this?
If healthcare does tend to act like a natural monopoly, then policymakers could look to the utility markets as an example for how to improve outcomes for people. Regulations in the utility market are designed to essentially simulate what the outcome would be for producers and consumers if the market was actually competitive.
Producers are guaranteed a return on their investment that is largely determined by what kinds of returns they could theoretically get in other competitive markets, and consumers get lower prices for electricity. The system isn’t perfect, but it largely does a good job of getting people electricity at reasonable prices, and it is almost certainly better than letting monopolies exert their full power.
If policymakers did attempt to regulate healthcare similarly to how they regulate utilities, they would have to overcome a number of problems. First is the fact that although there is a lot of consolidation, healthcare is clearly not exhibiting the same kind of monopolistic tendencies that utilities have. There are still a large number of independent practices that are able to compete, but would likely be crowded out if the government got involved with larger regulated systems.
Additionally, it would likely be prohibitively difficult to try to determine a fair price in all healthcare situations. A regulator would need to know what a healthcare provider's costs should be, what level of profit represents a reasonable return, and how much of the savings from consolidation should be passed on to patients or insurers. Healthcare is a much more varied service than utilities provide, and reaching a fair resolution for all sides would not be an easy task.
Still, this framework relies on the assumption that healthcare is a natural monopoly rather than a regular monopoly. In 2024, the Federal Trade Commission and Department of Justice began looking into healthcare mergers, specifically trying to determine if this type of consolidation was leading to higher prices without any noticeable benefit.
The key difference between these two situations is that it is more efficient to allow a natural monopoly to exist with regulations, and it is more efficient to break up regular monopolies and allow competitive factors to drive efficient market outcomes.
Either way, policymakers should be aware that this consolidation in the healthcare industry is happening. It doesn’t appear so far as if this integration is increasing efficiency, but this could change over time. If it does, then it could be beneficial to try and create a framework that protects patients from high costs, otherwise it might require action to preserve the efficiency that comes from competitive markets.
