Proactive Telehealth-Based Sepsis Transition and Recovery Support, Hospital Readmission, and Mortality: A Randomized Clinical Trial.

Vertical integration between insurers and specialty pharmacies, especially when aligned with integrated primary care, was associated with substantially faster access to specialty medications and lower beneficiary costs, suggesting that coordinated payer–pharmacy models may enhance both affordability and timely care for Medicare Advantage beneficiaries. Health care in the United States has undergone increasing consolidation over the past 2 decades. Much of this has occurred through horizontal integration, where organizations operating at the same level of the supply chain merge their operations (eg, hospital–hospital mergers). Such mergers are associated with higher prices and no improvements in health outcomes, leading to greater scrutiny by regulators. Considerably less attention has been given to other types of consolidation in health care, notably vertical integration between payers and providers (ie, hospitals, physician groups, and pharmacies), that operate at different levels of the supply chain. This type of integration has grown in recent years and, to our knowledge, has not been assessed thoroughly. Within vertical integration, most studies have evaluated provider consolidation that does not include payers, with mixed findings. For example, integration between health systems and physician groups led to higher spending and more patient steering (ie, health care entities directing patients to their own providers and hospitals) without subsequent improvement in hospital admissions or emergency department visits. On the other hand, integration between hospitals or physician organizations and pharmacies has been associated with lower prices for high-cost medications and increased cost savings for patients who used the integrated pharmacies. Integrations that include payers (eg, insurance companies) may better align both clinical and financial incentives. Aligning incentives between insurers and providers (eg, pharmacies) may reduce care fragmentation and lead to improved access to care and better patient experiences and health outcomes.. Policymakers raise concerns that such consolidation between insurers and providers may result in higher costs and care access barriers without health outcome improvements, similar to the effects of horizontal integration. Recent evidence found that prices increased after Optum, which is vertically integrated with an insurer, acquired physician practices. Emerging evidence in payer–provider integration focuses on Medicare Advantage (MA) models, suggesting that MA–hospital integration may better coordinate care and improve health outcomes. Increasingly, some MA models also integrate pharmacy care (ie, retail, mail order, or specialty pharmacies), which has garnered substantial recent interest from policymakers and antitrust organizations. Pharmacies owned by the largest MA insurers—CVS (Aetna), OptumRx (United Healthcare), CenterWell (Humana), and Express Scripts/Accredo (Cigna)—accounted for over one-third of Medicare pharmacy spending in 2021. Recent research suggests that MA insurers’ own enrollees are more likely to use the integrated pharmacy than enrollees in other insurers' plans. Policymakers and antitrust regulators have expressed concern that insurer–pharmacy vertical integration could reduce competition, leading to higher prices and foreclosure of nonintegrated pharmacies and insurers. However, there is a lack of peer-reviewed research assessing the impact of such payer–pharmacy vertical integration.