The role of the United States’ antitrust laws are to ensure competition, not to prescribe or favor any particular organizational structure. Yet recent Federal Trade Commission (“FTC”) enforcement actions in the health care provider merger arena have done just that – dictated that if provider groups want to integrate, they can only do so through contractual means, not by merging their businesses. Everyone accepts the proposition that health care integration is essential to improving health care and bending the cost curve. Yet often the FTC has been a roadblock to provider consolidation arguing that any efficiencies can be achieved through separate contracting. But this regulatory second guessing is inconsistent with sound health care and competition policy.
Health care provider consolidation poses some of the most challenging antitrust issues. Particularly challenging are efforts by hospitals to acquire or integrate with physician practices. There is clearly tremendous pressure from both the demand and supply side for greater integration between hospital and physicians. And arrangements between firms in a vertical relationship are treated solicitously by the antitrust laws, because they are typically procompetitive and efficient. Where competitive concerns arise from a merger or alliance, the FTC will ask if there are efficiencies from the relationship and, if so, whether there are less restrictive alternatives to achieve the efficiencies. If there is a less restrictive alternative, the FTC will claim the efficiencies should not be credited. So for example, if the FTC believes that contractual arrangements between doctors and hospitals can achieve comparable efficiencies, the FTC will reject the merging parties’ claimed efficiencies.
Front and center in this debate is the challenge to a Boise, Idaho hospital’s vertical acquisition of a physician practice, Saltzer Medical Group, containing 41 doctors in a neighboring community. In FTC v. St. Luke’s Health System, Ltd., No. 13-cv-00116 (D. Idaho, Jan. 24, 2014), the FTC argued that St. Luke’s acquisition of Saltzer’s 16 primary care doctors could substantially lessen competition for “Adult Primary Care Services” in Nampa, Idaho. Although noting numerous benefits of the merger including the likely improvement of patient outcomes, the court ignored the potentially positive implications of the vertical employment arrangement between St. Luke’s and Saltzer and ultimately agreed with the FTC’s opinion that the case was a substantially lessening of competition due to a horizontal overlap between providers. As a result, the court ordered a full divesture of Saltzer.
The court readily acknowledged the need for integration among these health care providers. “The merger require[s] a major shift away from our fragmented delivery system toward a more integrated system where primary care physicians supervise the work of a team of specialists, all committed to a common goal of improving a patient’s health…[St. Luke’s] is to be applauded for its efforts to improve the delivery of healthcare.” Nonetheless, the court followed the lead of the FTC and ultimately required the breakup of St. Luke’s and Saltzer. (A decision currently on appeal to the Ninth Circuit).
Why, you ask?
Because the court bought-in to the FTC’s argument that there are less restrictive ways to achieve the desired integration than through a merger. The court suggested, for example, that “employing physicians,” as St. Luke’s would do through the merger, is merely only one way to integrate and coordinate care. The court relied on the FTC’s claims that “there are a number of organizational structures that will create a team of unified and committed physicians other than that selected by the Acquisition.” The mere existence of such alternatives, without having demonstrated the effectiveness of such alternatives in the Nampa, Idaho setting, was enough for the FTC to argue there were less restrictive alternatives to the merger.
The FTC’s untested arguments utilized in St. Luke’s ignore basic market realities faced by health care providers. As has been well documented, cost-control through the integration of health care services is a critical national priority. Americans spend 18 percent of U.S. gross domestic product on health care. One major reason for high health care costs is the “siloed-approach” to medicine in which providers work autonomously and are ineffective in their ability to coordinate care with other providers. In order to curtail rising costs and improve care, health policies and laws, such as the Affordable Care Act, have led to a transformational change in providing health care services and payment: the decline of volume-based fee-for-service payment in favor of a value-based, patient outcome oriented approach. As noted by the American Hospital Association, these policy changes have created strong financial pressures for hospitals to reduce costs as providers face reductions in reimbursement, changed incentives, and limited access to capital.
When generally comparing mergers to contracting, economists have long noted that mergers are more efficient when transactions costs are high and there are “too many contingencies” in writing or enforcing a contract. These very conditions are found in health care markets where the market is in constant flux, there is limited information, and products are highly specialized. Along with economic theory, there are also a number of other reasons why “alternative” arrangements such as contractual arrangements among providers, even when available, are impractical alternatives to provider mergers.
First, mergers offer the most cost-effective way for providers to integrate and improve quality of care. As demanded by health reform, providers must act as cost-savers and are required to tie financial incentives to improving care.  The changes require providers to lower cost and achieve higher quality while simultaneously developing sufficient scale to bear risk from incentive based contracts. Under this new system, the most successful entities will have the appropriate economies of scale and scope to promote this structural change. While unaffiliated physicians and small group practices are on the frontlines of health care offering primary services, these providers do not have nor resources to develop integrated delivery models. Tightly integrated merged entities can develop sufficient scale and scope, can efficiently coordinate care between physicians, and are easily able to share information and adopt programs that can facilitate this fundamental change.
Second, high-level care coordination requires significant investment including the usage of complex health information technology systems. These information systems are extremely costly to both implement and operate requiring significant investment with a price tag in the nine-figure range. Many smaller provider groups, including physician practices, cannot afford to implement such systems. As noted by the parties in St. Luke’s, Saltzer, a mid-size physician practice, “needed to upgrade its medical record system and health information technology to keep pace with industry, but could not afford to do so without partnering with a large system.”
Third, mergers have been the most effective and competitive integration method. Most health care provider mergers are viewed as procompetitive. In fact, since 2008, less than two percent of all hospital mergers have been challenged in court. Provider mergers have also been very successful at increasing consumer benefits. In their recent Center for Healthcare Economic and Policy study on hospital realignment, Margaret E. Guerin-Calvert and Jen A. Maki found that mergers between hospital providers generally lead to significant “improvements in access, value, and efficiency.”
There are also numerous real world examples of fully vertically integrated entities that have led to effective provider integration. Renowned health care organizations such as Geisinger Health System and Intermountain Healthcare in Utah have utilized integrated systems through employment of physicians to successfully improve patient benefits such as service quality, institute preventive health measures, and lower costs. The models utilized by these organizations and others promote integration and efficiencies that could not be achieved through provider contracting.
Furthermore, there is real world evidence of the effectiveness of the merger model in incentivizing quality of care and lower price. Nationally, the vast majority of payment is fee-for-service with only 11 percent of all health care dollars being “value-oriented,” tied to financial incentives or risk. However, in California, 42 percent of all health care payments are value-oriented with 97 percent of those payments “at risk.” As noted by economist Monica Noether, California’s Kaiser Permanente, which owns hospitals, employs physicians, and operates a health plan as part of an integrated network, covers a large portion of the state’s privately insured lives and effectively utilizes value-oriented contracts with its providers. Without Kaiser’s integrated system, California would be unlikely to have such a high percentage of value-oriented care.
Lastly, while contracting arrangements sometimes may offer the best compromise for a particular provider affiliation, it is often an ineffective alternative compared to a tightly integrated merger. In fact, as noted by the court in St. Luke’s, Saltzer had “made attempts to coordinate care with other health systems under less-formal affiliations” but “none of these projects came to fruition.” Contractual agreements or joint ventures between providers create structural and coordination hurdles. Providers who jointly contract must comply with a complex, outdated regulatory system. Laws such as the Federal Anti-Kickback Statute and the Physician Self-Referral Law, more commonly known as the Stark Law, complicate initiatives among providers attempting to incentivize cooperation among providers. The application of a joint venture between parties also does not exempt providers from the antitrust laws. The review process at the FTC for lawful joint ventures still requires agency analysis and scrutiny, which can take over a year to complete, delaying any benefits of integration efficiently achieved through a merger.
Beyond regulations, contractual arrangements are time sensitive, costly, and complex creating numerous non-legal obstacles. Under such circumstances, parties can find it difficult to utilize a limited contractual arrangement to inform structural change which will align incentives and improve quality of care. Any notion that contracting is a more effective alternative to achieving integrated care when compared to mergers is unsubstantiated. As the antitrust enforcers’ own Merger Guidelines pronounce “the Agencies do not insist upon a less restrictive alternative that is merely theoretical.”
Integration is necessary to improve the delivery of health care in this country. Still, the St. Luke’s court was correct in one assertion: in the delivery of health care, “there are a number of organizational structures.” However, the implementation of different organizational structures to promote coordination and quality of care must comport with market, regulatory, and provider realities. What works for some health care providers will not work for all. Therefore, in the competitive analysis of provider mergers, enforcers should not invariably argue that contracting always represents the least restrictive alternative. Such blanket assertions are improper and not founded in practice-based evidence. In actuality, mergers between health care providers often remain the most effective way to transition health care practice to a fully integrated patient-centered model. The FTC and the courts should not permit the perfect to be the enemy of the good.
David Balto is an antitrust attorney an a former director of the FTC’s bureau of competition.
 ProMedica Health System, Inc. v. FTC, No. 12-3583, affirmed 2014 U.S. App. LEXIS 7500, (6th Cir. Apr. 22, 2014); FTC v. OSF Healthcare Sys., 852 F. Supp. 2d 1069 (N.D. Ill. 2012); In the Matter of Reading Health Sys., FTC Docket No. 9353 (Nov. 16, 2012).
 FTC v. St. Luke’s Health System, Ltd., No. 13-cv-00116 at 47.
 Amitabh Chandra et al., Is This Time Different? The Slowdown in Health Care Spending, Brookings Inst. (2013), available at http://www.brookings.edu/~/media/Projects/BPEA/Fall%202013/2013b_chandra_healthcare_spending.pdf.
 Fundamental Transformation of the Hospital Field, Am. Hospital Assoc. (2012), available at http://www.aha.org/content/13/fundamentaltransform.pdf.
 See Ronald Coase, The Nature of the Firm, 4 Economica 386, (1937)
 Monica Noether, The St. Luke’s-Saltzer Antitrust Case: Can Antitrust and Health Care Reform Policies Converge?, 2 CPI Antitrust Chronicle 1, 5 (2014).
 Noether, supra note 6, at 5.
 FTC v. St. Luke’s Health System, Ltd., No. 13-cv-00116 at 8.
 Margaret E. Guerin-Calvert & Jen A. Maki, Hospital Realignment: Mergers Offer Significant Patient and Community Benefits (2014), available at http://www.fticonsulting.com/global2/media/collateral/united-states/hospital-realignment-mergers-offer-significant-patient-and-community-benefits.pdf.
 Catalyst for Payment Reform, Only 11 Percent of Payment to Doctors and Hospitals in the Commercial Sector Today is tied to Their Performance at 1 (2013), available at http://www.catalyzepay mentreform.org/images /documents/release.
 See Noether, supra note 6, at 6.
 FTC v. St. Luke’s Health System, Ltd., No. 13-cv-00116 at 8 (emphasis added).
 U.S. Dep’t of Justice & Fed. Trade Comm’n, Horizontal Merger Guidelines at § 10 (2010), available at http://www.justice.gov/atr/public/guidelines/hmg-2010.pdf (emphasis added).
 FTC v. St. Luke’s Health System, Ltd., No. 13-cv-00116 at 47.
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David Balto claims that FTC enforcement action in, among other cases, Saint Alphonsus Regional Medical Center – Nampa, Inc. v. St. Luke’s Health System, Ltd., 12-cv-00560 (12-cv-00560-BLW (D. Idaho Jan. 24, 2014), interferes with hospital efforts to reduce costs and improve the quality of care . Unfortunately, Mr. Balto’s argument is strong on rhetoric, and light on facts.
The evidence in the St. Luke’s case, as well as every recent academic study, points strongly to the opposite conclusion. Acquisition of physician practices by hospitals does not lead to improved cost or quality. And it certainly does not offer any advantage over the efforts all across the United States by hospitals to work with independent physicians to achieve the very same goals.
This conclusion, the opposite of what Mr. Balto advocates, is made amply clear by overwhelming evidence from the St. Luke’s trial:
• St. Luke’s own experts have been unable to quantify any efficiencies to date resulting from its 40 previous physician practice acquisitions.
• As a result, unsurprisingly, St. Luke’s own expert admitted that St. Luke’s efforts to improve quality are far from established. Instead, they involve a “long and complicated path,” a “perilous route,” which would take 10 years or more and which might not succeed.
• Scores of hospitals nationally have worked with independent physicians to improve care. Independent physician practices have led the way in Idaho in improving immunization rates, asthma care, diabetes care and appropriate use of antibiotics. St. Luke’s employed physicians applied the same quality methods as independents that they utilize today.
• In fact, St. Luke’s Executive Medical Director identified 11 specific quality initiatives undertaken by St. Luke’s. In every case, according to his own admission, these initiatives either: (1) significantly involved independent physicians, and/or (2) were matched by similar programs around the country, including those which involve independent physicians.
• St. Luke’s argued that employment will allow it to compensate its employed physicians for quality and cost improvements. Yet hospitals in Idaho have adopted such payment methods for independent orthopedists, pulmonologists, ER physicians and anesthesiologists. In fact, quality incentives are being applied to all independent physicians by the federal Medicare program.
• Proven electronic health records (“EHR”) systems, adopted by hundreds of hospitals, work with the multiple platforms used by independent physicians. St. Luke’s own EHR system is being offered to independent, as well as employed, physicians, and 15 groups of independent physicians have expressed interest.
• St. Luke’s states on its website that “[c]linical integration with independent providers is clearly the essential building block of accountable care.” In fact, St. Luke’s believes that it is not “necessary for a physician to make referrals exclusively within one system or another in order to participate effectively in coordinated care and clinical integration.”
The academic studies even more strongly rebut Mr. Balto’s thesis. They indicate that, if anything, larger physician practices and those owned by hospitals are less successful in controlling cost or quality than medium sized independent practices. For example, a 2013 study found that independent physician groups provided higher quality, lower cost care compared to physicians employed by hospitals. Journal of American Medical Association Internal Medicine, McWilliams, et al., “Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries.” JAMA Intern Med. 2013:173(15):147-1456. The same result was also found in a just published study, Robinson, “Total Expenditures per Patient in Hospital-Owned and Physician-Owned Physician Organizations in California.” JAMA. 2014: 312(16);1663-1669.
Mr. Balto’s piece ignores another inconvenient fact – that the vast majority of health care transactions are not the subject of antitrust concern. This is also illustrated by the St. Luke’s case. The District Court found that St. Luke’s, the defendant, had acquired more than 40 physician practices prior to the acquisition – of the largest and oldest practice in Idaho – that led to an antitrust challenge. Even if there were efficiencies to be had from these acquisitions, antitrust issues affected only one out of more than 40 such transactions.
The St. Luke’s case also illustrates the real dangers addressed by antitrust enforcement. The court found, based on specific evidence from St. Luke’s and its own consultants, that the transaction was expected to raise prices. Indeed, the defendants’ own documents referred to the increased “clout” and the ability to “control market share” that they would gain from the transaction. They specifically referred to their ability to obtain “higher hospital-based reimbursement” from health plans after the transaction was complete, even estimating these increases at greater than 60%.
In light of these admissions, it is not surprising one of St. Luke’s own physician executives stated that “the system is making decisions based on dollars and strategy regardless of quality . . .”
Arguments like Mr. Balto’s should not be permitted to interfere with antitrust enforcement when there is real evidence of harm to purchasers, and, ultimately, consumers. That is why organizations such as Catalyst for Payment Reform, America’s Health Insurance Plans, and the Association of Independent Doctors, representing critically important players in the health care marketplace, have filed amicus curiae briefs seeking that the District Court’s findings in St. Luke’s be affirmed.
 Mr. Balto, like I do, has an interest in this case. He filed an amicus curiae brief in the St. Luke’s appeal. I represent the Saint Alphonsus plaintiffs in that case.
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I agree with Robert, the author has a very one sided view and opinion.He should by all means complete research prior to publishing. You can easily google reports from several foundations including the kaiser foundation. Such reports the unbias facts on what the current trajectory of bigness in health care under the ACA is really costing the consumer under such monopolies. I live in Central Connecticut and Im watching this happen first hand. One big health care system driving out good low cost competition, playing hardball with pricing and actually reducing quality of care. It seems to me that the lack of the freedom to choose by the consumer will have serious detrimental overall consequences to the consumer. The FTC needs to enforce investigate antitrust actions here.
Very Ironic that a discussion of provider mergers and integrated systems in the name of competition and markets is completely devoid of any facts about provider market leverage, market influence, and bargaining power. This article is a gross display of ignorance. The assertions this author makes about the positive benefits of provider consolidation are scary and disconcerting. He should start by doing some actual research on provider consolidation and prices, and he’ll find the evidence to be overwhelming – provider consolidaiton, integrated systems, and mergers have time and time again resulted in increased prices because of greater bargaining power. Scary to think that this individual was bureau chief of competition at the FTC! NO wonder ACOs are getting a free pass on anti-trust and creating regional monopolies.
Before you write an article about this you should probably find out the real reason Saltzer entered into this arrangement in the first place and it had nothing to do with not being able to afford electronic health records or better patient experience. In fact, they have a more robust system and have achieved meaningful use without St. Luke’s assistance. It was about money, pure and simple.
“Everyone accepts the proposition that health care integration is essential to improving health care and bending the cost curve.”
Not on planet earth. Or, at least not in the United States.
I think the author ought to write a sequel to this: why consolidation of hospitals doesn’t lead to reduction in marginal costs despite the economies of scale.
That’s the interesting analysis.
I wish I could “Like” every single one of the previous comments.
“In actuality, mergers between health care providers often remain the most effective way to transition health care practice to a fully integrated patient-centered model.”
In the immortal words of J.K. Rowling, “…this would be optimistic to the point of foolishness.”
Have you read it? Your take? I just saved it and will study it.
“One major reason for high health care costs is the “siloed-approach” to medicine in which providers work autonomously and are ineffective in their ability to coordinate care with other providers.”
Hospital dominated health care, in which hospital systems buy up all of the (formerly) independent physicians – to give them even greater leverage in negotiations with insurance reimbursements – and then requires all testing and treatment orders go to that hospital systems (self-referral) providers which are 2 to 5 times more expensive than the testing and treatment done outside of the hospital system has been the biggest driver of increased healthcare costs.
If merging will provide increased savings its naive to think the hospital system will pass those savings onto the consumer/patient. What the hospital system will do is use their newly acquired bargaining power to get higher rates and drive premiums up.
ANY association with hospital networks will NOT “bend” the cost curve. My direct experience is they at least double the cost.
And Yes, I agree with above posters – NO. everyone does not agree, unless hospitals are the “everyone”.
“The role of the United States’ antitrust laws are to ensure competition”
and, competition is antithetical to capitalism. See Peter Theil, “Zero to One” –
4. THE IDEOLOGY OF COMPETITION
CREATIVE MONOPOLY means new products that benefit everybody and sustainable profits for the creator. Competition means no profits for anybody, no meaningful differentiation, and a struggle for survival. So why do people believe that competition is healthy? The answer is that competition is not just an economic concept or a simple inconvenience that individuals and companies must deal with in the marketplace. More than anything else, competition is an ideology— the ideology— that pervades our society and distorts our thinking. We preach competition, internalize its necessity, and enact its commandments; and as a result, we trap ourselves within it—even though the more we compete, the less we gain.
This is a simple truth, but we’ve all been trained to ignore it…
3. RUTHLESS PEOPLE
The competitive ecosystem pushes people toward ruthlessness or death.
A monopoly like Google is different. Since it doesn’t have to worry about competing with anyone, it has wider latitude to care about its workers, its products, and its impact on the wider world. Google’s motto—“ Don’t be evil”— is in part a branding ploy, but it’s also characteristic of a kind of business that’s successful enough to take ethics seriously without jeopardizing its own existence. In business, money is either an important thing or it is everything. Monopolists can afford to think about things other than making money; non-monopolists can’t. In perfect competition, a business is so focused on today’s margins that it can’t possibly plan for a long-term future. Only one thing can allow a business to transcend the daily brute struggle for survival: monopoly profits.
So, a monopoly is good for everyone on the inside, but what about everyone on the outside? Do outsized profits come at the expense of the rest of society? Actually, yes: profits come out of customers’ wallets, and monopolies deserve their bad reputation— but only in a world where nothing changes.
In a static world, a monopolist is just a rent collector. If you corner the market for something, you can jack up the price; others will have no choice but to buy from you. Think of the famous board game: deeds are shuffled around from player to player, but the board never changes. There’s no way to win by inventing a better kind of real estate development. The relative values of the properties are fixed for all time, so all you can do is try to buy them up.
But the world we live in is dynamic: it’s possible to invent new and better things. Creative monopolists give customers more choices by adding entirely new categories of abundance to the world. Creative monopolies aren’t just good for the rest of society; they’re powerful engines for making it better.
Even the government knows this: that’s why one of its departments works hard to create monopolies (by granting patents to new inventions) even though another part hunts them down (by prosecuting antitrust cases). It’s possible to question whether anyone should really be awarded a legally enforceable monopoly simply for having been the first to think of something like a mobile software design. But it’s clear that something like Apple’s monopoly profits from designing, producing, and marketing the iPhone were the reward for creating greater abundance, not artificial scarcity: customers were happy to finally have the choice of paying high prices to get a smartphone that actually works…
Not that I buy all of Theil unreflectively. But, according to the Libertarians’ beloved “market efficiency uber alles,” the most efficient market is also the lowest profit, by definition.
“Monopolies drive progress because the promise of years or even decades of monopoly profits provides a powerful incentive to innovate. Then monopolies can keep innovating because profits enable them to make the long-term plans and to finance the ambitious research projects that firms locked in competition can’t dream of.
So why are economists obsessed with competition as an ideal state? It’s a relic of history. Economists copied their mathematics from the work of 19th-century physicists: they see individuals and businesses as interchangeable atoms, not as unique creators. Their theories describe an equilibrium state of perfect competition because that’s what’s easy to model, not because it represents the best of business. But it’s worth recalling that the long-run equilibrium predicted by 19th-century physics was a state in which all energy is evenly distributed and everything comes to rest— also known as the heat death of the universe.
Whatever your views on thermodynamics , it’s a powerful metaphor: in business, equilibrium means stasis, and stasis means death. If your industry is in a competitive equilibrium, the death of your business won’t matter to the world; some other undifferentiated competitor will always be ready to take your place.
Perfect equilibrium may describe the void that is most of the universe. It may even characterize many businesses. But every new creation takes place far from equilibrium. In the real world outside economic theory, every business is successful exactly to the extent that it does something others cannot. Monopoly is therefore not a pathology or an exception. Monopoly is the condition of every successful business.
Tolstoy opens Anna Karenina by observing: “All happy families are alike; each unhappy family is unhappy in its own way.” Business is the opposite. All happy companies are different: each one earns a monopoly by solving a unique problem. All failed companies are the same: they failed to escape competition…”
“Actually, yes: profits come out of customers’ wallets, and monopolies deserve their bad reputation— but only in a world where nothing changes.”
Change can come very very slowly. Regulated market monopolies can be efficient but if they are investor owned they may not “do no evil”.
Here in NC Duke Power is very efficient and prices are quite good, but they also are run by their Wall Street investors who don’t care about being evil. That is what probably accounted for decades of criminal cheap disposal of coal ash with collusion from our department of environment (oxymoron).
Is hospital chargemaster being efficient, providing benefits to society? I doubt it.
So, as with all things, maybe.
“Monopolies drive progress because the promise of years or even decades of monopoly profits provides a powerful incentive to innovate.”
Indeed. Schumpeter made the same observation (see “Will Capitalism Survive”).
I do not think medical innovation would have been what it is today in a government-distorted third party payer system, in a genuine free market.
COI: Libertarian (most of the time)
“Everyone accepts the proposition that health care integration is essential to improving health care and bending the cost curve”
Um . . . no.
“and bending the cost curve”
Improving health care today, as noble an effort as it is in its own right, only guarantees that you will face and older and sicker (and more expensive) patient in the future.