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Cardiac rehabilitation (CR) is a medically supervised program designed to improve heart health after a cardiac event. Despite its demonstrated clinical benefits, CR participation among eligible patients remains poor due to low referral rates and individual barriers to care. To evaluate CR participation by patients who receive care from hospital-integrated physicians compared with independent physicians, and subsequently, to examine CR and recurrent cardiac hospitalizations. This retrospective cohort study evaluated Medicare Part A and Part B claims data from calendar years 2016 to 2019. All analyses were conducted between January 1 and April 30, 2024. Patients were included if they had a qualifying event for CR between 2017 and 2018, and qualifying events were identified using diagnosis codes on inpatient claims and procedure codes on outpatient and carrier claims. Eligible patients also had to continuously enroll in fee-for-service Medicare for 12 months or more before and after the index event. Physicians’ integration status and patients’ CR participation were determined during the 12-month follow-up period. The study covariates were ascertained during the 12 months before the index event. ExposureHospital-integration status of the treating physician during follow-up. Main Outcomes and MeasuresPostindex CR participation was determined by qualifying procedure codes on outpatient and carrier claims. ResultsThe study consisted of 28 596 Medicare patients eligible for CR. Their mean (SD) age was 74.0 (9.6) years; 16 839 (58.9%) were male. A total of 9037 patients (31.6%) were treated by a hospital-integrated physician, of which 2995 (33.1%) received CR during follow-up. Logistic regression via propensity score weighting showed that having a hospital-integrated physician was associated with an 11% increase in the odds of receiving CR (odds ratio [OR], 1.11; 95% CI, 1.05-1.18). Additionally, CR participation was associated with a 14% decrease in the odds of recurrent cardiovascular-related hospitalizations (OR, 0.86; 95% CI, 0.81-0.91). The findings of this cohort study suggest that hospital integration has the potential to facilitate greater CR participation and improve heart care. Several factors may help explain this positive association, including enhanced care coordination and value-based payment policies. Further research is needed to assess the association of integration with other appropriate high-quality care activities.
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How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry*
Abstract Many industries have become increasingly concentrated through mergers and acquisitions, which in health care may have important consequences for spending and outcomes. Using a rich panel of Medicare claims data for nearly one million dialysis patients, we advance the literature on the effects of mergers and acquisitions by studying the precise ways providers change their behavior following an acquisition. We base our empirical analysis on more than 1,200 acquisitions of independent dialysis facilities by large chains over a 12-year period and find that chains transfer several prominent strategies to the facilities they acquire. Most notably, acquired facilities converge to the behavior of their new parent companies by increasing patients’ doses of highly reimbursed drugs, replacing high-skill nurses with less-skilled technicians, and waitlisting fewer patients for kidney transplants. We then show that patients fare worse as a result of these changes: outcomes such as hospitalizations and mortality deteriorate, with our long panel allowing us to identify these effects from within-facility or within-patient variation around the acquisitions. Because overall Medicare spending increases at acquired facilities, mostly as a result of higher drug reimbursements, this decline in quality corresponds to a decline in value for payers. We conclude the article by considering the channels through which acquisitions produce such large changes in provider behavior and outcomes, finding that increased market power cannot explain the decline in quality. Rather, the adoption of the acquiring firm’s strategies and practices drives our main results, with greater economies of scale for drug purchasing responsible for more than half of the change in profits following an acquisition.
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- Award ID(s):
- 1851615
- PAR ID:
- 10180446
- Date Published:
- Journal Name:
- The Quarterly Journal of Economics
- Volume:
- 135
- Issue:
- 1
- ISSN:
- 0033-5533
- Page Range / eLocation ID:
- 221 to 267
- Format(s):
- Medium: X
- Sponsoring Org:
- National Science Foundation
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- Free Publicly Accessible Full Text
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Accepted Manuscript1.0
- Journal Article:
- https://doi.org/10.1093/qje/qjz034
