Systematic Review of Integration Strategies Across the US Healthcare System: Assessment of Price, Cost, and Quality of Care

Abstract

Background: In the last 30 years, consolidation of healthcare systems in the US has accelerated through mergers and acquisitions. We completed a systematic literature review on integration to determine if its reputation for enhancing the value of healthcare by reducing price as well as cost and spending and improving overall quality of care is justified.

Study design: A systematic review of the literature was completed for articles published in the US from 1990 to 2024. Primary inclusion criteria were horizontal integration (HI, joining 2 or more hospitals) and vertical integration (VI, merging of physicians and hospitals) and reporting on at least 1 measure of value (price, cost and spending, or quality).

Results: Neither HI nor VI has resulted in consistent and significant improvements in price, cost or spending, or quality associated with healthcare delivery. We screened 1,297 articles and identified 37 that met inclusion criteria. Results from any form of integration were mixed. Thirteen of 14 studies (93%) about price reported price increases. Thirteen of 16 studies (81%) about cost and spending showed cost increases or no change. Twenty of 26 studies (77%) about quality showed reductions or no change from integration (HI, VI, or both).

Conclusions: Our review suggests that evidence is lacking to support the theory that integration is an effective strategy for improving the value of healthcare delivery. This finding represents an opportunity for healthcare leaders, including surgeons, to better define value in their efforts to improve quality while balancing the financial stability of the healthcare industry with a focus on benefiting the patient.