How Health System Consolidation Could Hurt Patients

Recently, health care consolidation—such as mergers of provider groups and acquisitions of provider groups by large payers—have become increasingly common. However, these consolidation attempts may actually adversely impact patient safety, according to a recent viewpoint commentary in JAMA.

In order to determine the impact of consolidation on patient safety, researchers at Harvard University, led by Susan Haas, MD, analyzed patient safety risks for Harvard-affiliated institutions by interviewing clinicians and health system leaders locally and nationally. The team of researchers identified 3 safety risks that were associated with changes to patient population, infrastructure, and clinician practice settings.

Patient Populations

Often times following a merger, health care systems experience a significant change in their patient population. The overall volume of patients increases, and there can also be changes to demographic characteristics or conditions that are new to a facility.

For institutions that anticipate these changes, unit-level adjustments such as training support staff are often in place, according to the study.

However, patient population changes are often not anticipated. Mergers often create an increase in referrals, which can increase the population of non-English speaking patients. A change like this quickly reveals any shortcomings, including lack of interpreters, lack of institutional relationship with different community services, and a deficit in awareness of economic and social challenges that these patients may face following care guidelines.

These unexpected changes in patient population may lead to a lack of wider institutional attention to specialized needs and can result in serious deficiencies in providing safe and timely care.

Health System Infrastructure

In order to achieve financial benefits during mergers, changes to health care systems often involve substantial changes in supplies, equipment, formularies, protocols, and information systems.

Due to these changes, however, clinicians now face significant challenges.
 “Even with training, a learning curve makes formerly routine tasks more time- and attention-intensive and error-prone; finding the correct form in an electronic health record for ordering a test, identifying the correct substitution medication and dose from a new formulary, or transferring a patient,” the authors of the study explained. “The attention clinicians must now give to once “automatic” tasks also distracts from other aspects of patient care or slows throughput.”

According to the authors of the study, an increased likelihood of major errors and patient dissatisfaction may occur unless schedules and capacity in the health system are adjusted.

Article continues on page 2

Clinician Practice Settings

According to a survey given to 82 health care institutions that have undergone expansions, 87% said they require physicians to travel to new practice sites. The most common traveling physicians include specialists such as cardiologists, surgeons, oncologists, and obstetricians.

Often when these clinicians are forced to travel to new practice settings, they receive little systematic orientation to their new setting. This leaves clinicians to practice in various and unexpected ways from what they are used to at their home institutions.

The study found that physicians said they adapt to their new circumstance through trial and error. However, because of this, patients are now put at risk. The trial and error attempts are typically used to determine the type of care that can be provided in a given setting and during emergency situations. Clinicians are often faced with unfamiliar crash carts and electronic health records.

“Physicians reported that although they know the right care to provide to patients, they commonly discovered situations in which they did not know how to deliver the care, and especially, how to do it quickly,” the authors wrote.

Mitigating Risks to Patients

In an effort to mitigate risks to patients from health system expansion, the authors of the study highlighted how a patient safety toolkit could support clinical planning between institutions prior to launch.

The toolkit provides guidance on topics to discuss among health care systems in an effort to resolve institutional differences that could result in patient safety risks. Further, the toolkit provides a checklist for establishing a joint clinical integration council. Although these tools have entered local use, the researchers explained that quality improvement and error reduction that may occur because of health care expansions is unknown.

Further research is still needed to better predict patient safety risk based on these approaches.

“System expansions can have substantial effects on clinical care and patient safety, particularly when clinicians encounter changes in their practice setting, patient population, or infrastructure,” the authors concluded.  “Institutions must actively plan for, monitor, and manage the resulting risks as part of a comprehensive strategy, including sharing data on quality and safety, and sharing oversight of care for the joint patient population.”

—Julie Gould

For more articles by IH Executive, click here

For similar articles by First Report Managed Care, click here