Provider consolidation has been associated with higher health care prices and spending. Prevailing wisdom assumes that payment reform will accelerate consolidation, especially between physicians and hospitals and among physician groups, as providers position themselves to bear financial risk for the full continuum of patient care. We examined the relationship between Medicare’s Accountable Care Organization (ACO) programs and provider consolidation. According to multiple measures, consolidation was underway before the Affordable Care Act (ACA) established the ACO programs. While hospital mergers and specialty-oriented physician group size increased after the ACA, we found minimal evidence associating consolidation with ACO penetration at a market level or with ACO participation by physicians within markets. We conclude that payment reform has been associated with little acceleration in consolidation overall beyond trends already underway, but with some evidence of potential defensive consolidation in response to new payment models.
Many physicians face increasing stress to see more patients in the same or less time. This leads to crowded appointment schedules and increased schedule disruptions. I examine how physicians respond to schedule disruptions, instrumenting for appointment start time with the office arrival time of the physician's previous patient. I use novel data from athenahealth, Inc., a national provider of electronic health records, medical billing, and practice management services. I find that when primary care physicians fall behind schedule, they truncate appointment duration, perform fewer in-office procedures, and record fewer diagnoses. The likelihood of a patient revisiting the primary care practice within two weeks significantly increases as a function of delayed appointment start time. Physician ordering behavior also responds to a schedule disruption. In particular, physicians who run behind schedule increase antibiotic and opioid painkiller prescribing and increase referrals of a new patient to a specialist. For patients with preexisting prescription drug regimens, physicians running behind schedule are less likely to change the existing course of treatment. These findings suggest possible unintended consequences of the increasing time pressures placed on physicians by policymakers and private payers. Implications may include higher health care spending and lower quality care.