The impact of hospital mergers on treatment intensity and health outcomes

Quality of care after a horizontal merger between two large academic hospitals

Background

Hospital mergers remain common, but their influence on healthcare quality varies. Data on effects of European hospital mergers are ill defined, and academic hospitals in particular. This case study assesses early quality of care changes in two formerly competing Dutch academic hospitals that merged on June 6, 2018.

Methods

Statistical process control and interrupted time series analysis were performed. All adult, non-psychiatric patients, admitted between 01-03-2016 and 01-10-2022 were eligible for analysis. Primary outcome measure was all cause in-hospital mortality (or hospice), secondary outcomes were unplanned 30-day readmissions to same hospital, length of stay, and patients' hospital rating. Data were obtained from electronic health records, and patient experience surveys.

Findings

The mean (SD) age of the 573 813 included patients was 54·3 (18·9) years. The minority was female (277 817, 48·4 %), and most admissions were acute (308 597, 53·8 %). No merger related change in mortality was found in the first 20 months post-merger (limited to the pre-Covid-19 era). For this same period, the 30-day readmission incidence changed to a downward slope post-merger, and the length of stay shortened (immediate level-change -3·796 % (95 % CI, -5·776 % to -1·816 %) and trend-change -0·150 % per month (95 % CI, -0·307 % to 0·007 %)). Patients' hospital ratings seemed to improve post-merger.

Interpretation

In this quality improvement study, a full- and gradual post-merger integration strategy for a Dutch academic hospital merger was not associated with changes in in-hospital mortality, and yielded slight improved results for secondary quality of care outcomes.

Emergency Department and Health Care System Factors Associated with Telehealth Innovation During the COVID-19 Pandemic

Objective: Telehealth capacity may be an important component of pandemic response infrastructure. We aimed to examine changes in the telehealth use by the US emergency departments (EDs) during COVID-19, and to determine whether existing telehealth infrastructure or increased system integration were associated with increased likelihood of use. Methods: We analyzed 2016-2020 National ED Inventory (NEDI)-USA data, including ED characteristics and nature of telehealth use for all US EDs. American Hospital Association data characterized EDs' system integration. An ordinary least-squares regression model obtained one-step-ahead forecast of the expected proportion of EDs using telehealth in 2020 based on growth observed from 2016 to 2019. Among EDs without telehealth in 2019, we used logistic regression models to examine whether system membership or existing telehealth infrastructure were associated with odds of innovation in telehealth use in 2020, accounting for ED characteristics. Results: Of 4,038 EDs responding to telehealth questions in 2019 and 2020 (73% response rate), 3,015 used telehealth in 2020. Telehealth use by US EDs increased more than expected in 2020 (2016: 58%, 2017: 61%, 2018: 65%, 2019: 67%, 2020: 74%, greater than predicted 71%, p = 0.004). Existing telehealth infrastructure was associated with increased telehealth innovation (OR = 1.88, 95% CI: 1.49-2.36), whereas hospital system membership was not (odds ratio [OR] = 1.00, 95% confidence interval [CI]: 0.80-1.25). Conclusions: Telehealth use by US EDs in 2020 grew more than expected and preexisting telehealth infrastructure was associated with increased innovation in its use. Preparation for future pandemic responses may benefit from considering strategies to invest in local infrastructure to facilitate technology adoption and innovation.

Health impacts in pathology workforce during mergers and acquisitions (M&A)

AIMS

To compare burn-out in laboratory professionals (LPs) with exposure to consolidation to those without, and to investigate the role of social support as a moderator in the exposure to mergers and acquisitions (M&A).

METHODS

Surveys were sent to the clinical LPs, including 732 with exposure to M&A and 819 without. The dependent variable was burn-out, and the independent variable was exposure to M&A. In investigating the role of social support in exposure group, a logistic regression was used with education, time since M&A, gender, merger types, practice setting, lab hierarchy and race as covariates.

RESULTS

Exposure to M&A was associated with higher levels of burn-out (p<0.05). In logistic regression of the workforce exposed to M&A, the odds for LP developing a high level of burn-out are lowered by 7.1% for every unit of increase in social support (OR 0.93; 95% CI 0.88 to 0.98; p=0.004).

CONCLUSION

LPs exposed to M&A are more likely to experience higher levels of burn-out but having social support can protect against burn-out, which has policy implications for leadership managing laboratories in times of M&A.

Changes in institution for mental diseases (IMD) ownership status and insurance acceptance over time

State Medicaid programs are prohibited from using federal dollars to pay institutions for mental diseases (IMDs)-freestanding psychiatric facilities with more than 16 beds. Increasingly, regulatory mechanisms have made payment of treatment in these settings substantially more feasible. This study evaluates if changing financial incentives are associated with increases in for-profit ownership among IMD facilities relative to non-IMD facilities, as well as greater increases in Medicaid acceptance among for-profit IMD facilities relative to for-profit non-IMD facilities. We used data from the 2014-2020 National Mental Health Services Surveys and examined 11 945 facility-years. Relative to non-IMDs, the increase in for-profit ownership among IMDs was 6.6 percentage points greater. The largest proportional change in Medicaid acceptance occurred among for-profit IMD facilities relative to for-profit non-IMDs (18.5 percentage points). Existing research is mixed on the quality of inpatient and residential psychiatric care provided in for-profit vs nonprofit and public facilities, as well as in IMD relative to non-IMD facilities. As payment policy increasingly incentivizes for-profit facilities to enter the psychiatric care space, we should be mindful of the impact of these decisions on patient safety.

Optimizing care delivery in expanding health systems: Views from clinical leaders

INTRODUCTION

In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored.

METHODS

Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis.

RESULTS

Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality.

CONCLUSIONS

Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.

Impact of hospital mergers: a systematic review focusing on healthcare quality measures

Background

Despite mergers have increasingly affected hospitals in the recent decades, literature on the impact of hospitals mergers on healthcare quality measures (HQM) is still lacking. Our research aimed to systematically review evidence regarding the impact of hospital mergers on HQM focusing especially on process indicators and clinical outcomes.

Methods

The search was carried out until January 2020 using the Population, Intervention, Comparison and Outcome model, querying electronic databases (MEDLINE, Scopus, Web Of Science) and refining the search with hand search. Studies that assessed HQM of hospitals that have undergone a merger were included. HQMs were analyzed through a narrative synthesis and a strength of the evidence analysis based on the quality of the studies and the consistency of the findings.

Results

The 16 articles, included in the narrative synthesis, reported inconsistent findings and few statistically significant results. All indicators analyzed showed an insufficient strength of evidence to achieve conclusive results. However, a tendency in the decrease of the number of beds, hospital staff and inpatient admissions and an increase in both mortality and readmission rate for acute myocardial infarction and stroke emerged in our analysis.

Conclusions

In our study, there is no strong evidence of improvement or worsening of HQM in hospital mergers. Since a limited amount of studies currently exists, additional studies are needed. In the meanwhile, hospital managers involved in mergers should adopt a clear evaluation framework with indicators that help to periodically and systematically assess HQM ascertaining that mergers ensure and primarily do not reduce the quality of care.

Quality of Care Before and After Mergers and Acquisitions of Rural Hospitals

IMPORTANCE

Rural hospitals are increasingly merging with other hospitals. The associations of hospital mergers with quality of care need further investigation.

OBJECTIVES

To examine changes in quality of care for patients at rural hospitals that merged compared with those that remained independent.

DESIGN, SETTING, AND PARTICIPANTS

In this case-control study, mergers at community nonrehabilitation hospitals in Federal Office of Rural Health Policy-eligible zip codes during 2009 to 2016 in 32 states were identified from Irving Levin Associates and the American Hospital Association Annual Survey. Outcomes for inpatient stays for select conditions and elective procedures were derived from the Healthcare Cost and Utilization Project State Inpatient Databases. Difference-in-differences linear probability models were used to assess premerger to postmerger changes in outcomes for patients discharged from merged vs comparison hospitals that remained independent. Data were analyzed from February to December 2020.

EXPOSURES

Hospital mergers.

MAIN OUTCOMES AND MEASURES

The main outcome was in-hospital mortality among patients admitted for acute myocardial infarction (AMI), heart failure, stroke, gastrointestinal hemorrhage, hip fracture, or pneumonia, as well as complications during stays for elective surgeries.

RESULTS

A total of 172 merged hospitals and 266 comparison hospitals were analyzed. After matching, baseline patient characteristics were similar for 303 747 medical stays and 175 970 surgical stays at merged hospitals and 461 092 medical stays and 278 070 surgical stays at comparison hospitals. In-hospital mortality among AMI stays decreased from premerger to postmerger at merged hospitals (9.4% to 5.0%) and comparison hospitals (7.9% to 6.3%). Adjusting for patient, hospital, and community characteristics, the decrease in in-hospital mortality among AMI stays 1 year postmerger was 1.755 (95% CI, -2.825 to -0.685) percentage points greater at merged hospitals than at comparison hospitals (P < .001). This finding held up to 4 years postmerger (DID, -2.039 [95% CI, -3.388 to -0.691] percentage points; P = .003). Greater premerger to postmerger decreases in mortality at merged vs comparison hospitals were also observed at 5 years postmerger among stays for heart failure (DID, -0.756 [95% CI, -1.448 to -0.064] percentage points; P = .03), stroke (DID, -1.667 [95% CI, -3.050 to -0.283] percentage points; P = .02), and pneumonia (DID, -0.862 [95% CI, -1.681 to -0.042] percentage points; P = .04).

CONCLUSIONS AND RELEVANCE

These findings suggest that rural hospital mergers were associated with better mortality outcomes for AMI and several other conditions. This finding is important to enhancing rural health care and reducing urban-rural disparities in quality of care.

Hospital Competition and Unplanned Readmission: Evidence from a Systematic Review

Competition has been widely introduced among hospitals in the hope of improving health-care quality. However, whether competition leads to higher-quality health care is a topic of considerable debate. We conducted a systematic review to assess the impact of hospital-market competition on unplanned readmission. We searched six electronic databases (PubMed, EmBase, Wiley Online Library, Web of Science, Scopus, and JSTOR) and reference lists of screened articles for relevant studies, and strictly followed methods proposed by the Cochrane Collaboration. Finally, nine observational studies with 2,241,767 patients were included. For the primary outcome, pooled results of three studies showed that it was uncertain whether or not hospital competition reduces readmission (β=0.02, P=0.06; very low certainty of evidence, as they were all observational studies with high heterogeneity). Inconsistent results were found in the remaining six studies, and they were assessed as very low–certainty evidence, downgraded for either inconsistency or indirectness or both. As for secondary outcomes, seven of the nine studies reported on the impact of competition on the risk of mortality, and two reported on length of stay (LOS). It was uncertain whether competition had an effect on mortality or LOS. The relevant studies were limited and of very low certainty, which means there is currently no reliable evidence showing that hospital competition reduces quality of health care in terms of readmission/mortality/LOS. There is a need for rigorous studies to assess the impact of hospital competition on the quality of health care.

If you say so: A mixed-method study of hospital mergers and quality of care

BACKGROUND

Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements.

PURPOSE

We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design.

METHODOLOGY

Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers.

RESULTS

Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers' quality implications, resulting from scale and shock effects.

CONCLUSION

The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy.

PRACTICE IMPLICATIONS

Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects.

Hospital network participation and outcomes following elective posterior lumbar fusions - are mergers effective?

BACKGROUND CONTEXT

Due to financial pressures associated with healthcare reforms, an increasing number of hospitals are now merging (or consolidating) into networks (or systems). However, it remains unclear how these mergers or network participations affect quality of care and/or costs.

PURPOSE

The current study aims to evaluate the impact of hospital network participation on 90-day complications, charges, and costs following elective posterior lumbar fusions (PLFs).

STUDY DESIGN

Retrospective review of a 100% national sample of Medicare claims from 2010 to 2014 (SAF100).

STUDY SAMPLE

All Medicare-eligible patients undergoing elective 1-to-3 level PLFs for degenerative lumbar pathology from 2010 to 2014.

OUTCOME MEASURES

Ninety-day complications, charges, and costs.

METHODS

The 2010 to 2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1- to 3-level PLFs for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network (or system) between 2010 and 2014. The study sample was divided into 2 cohorts (network hospitals and non-network hospitals) for analyses. Multivariate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location, and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs.

RESULTS

A total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study, out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were more prevalent in the South or West regions of the United States. Patients in network hospitals had a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1- to 3-level PLFs, greater number of beds, be located in an urban location, and have a voluntary/nonprofit or proprietary/profit ownership model. Multivariate analyses showed that even though patients undergoing surgery at network hospitals (vs non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs 7.4%, odds ratio [OR] 1.07 [95% confidence interval {CI} 1.02-1.12]; p=.010), thromboembolic complications (2.4% vs 2.2%, OR 1.12 [95% CI 1.01-1.20]; p=.025) and emergency department visits (16.4% vs 16.0%, OR 1.06 [95% CI 1.02-1.09]; p=.002), the differences would not be considered clinically significant. Despite a slight decrease in risk-adjusted 90-day reimbursements (-$272), the risk-adjusted 90-day charges were actually significantly higher (+$9,959; p<.001) at network hospitals.

CONCLUSIONS

Even though hospitals that are part of a network do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks.

Merging Two Hospitals: The Effects on Pediatric Extracorporeal Cardiopulmonary Resuscitation Outcomes

In this article, a retrospective study was performed to describe the impact of merging two pediatric intensive care units on the overall and neurocognitive outcomes of children who required extracorporeal cardiopulmonary resuscitation (ECPR). Results from three cohorts were compared: 2008 to 2014: premerge, 2014 to 2017: initial time period postmerge, and 2018 to 2019: established merge. Survival to hospital discharge (and with good neurological outcome) was of 68% (61%), 46% (36%), and 79% (71%), respectively, for the three time periods. Merging two hospitals resulted in a nonsignificant trend toward temporary worse outcomes in pediatric patients requiring ECPR.

Provider Practice Competition and Adoption of Medicare's Oncology Care Model

BACKGROUND

There is a concern that the Oncology Care Model (OCM), a voluntary bundled payment program, may incentivize mergers and acquisitions among physician practices leading to reduced competition and price increases. These concerns are heightened if OCM is preferentially adopted in competitive health care markets because it could result in reduced competition, but little is known about the characteristics of markets where OCM is adopted.

OBJECTIVE

To measure the association between regional market competition among medical oncologists with the initial adoption of OCM.

RESEARCH DESIGN

The Herfindahl-Hirschman Index (HHI), a measure of competition, was calculated for hospital referral regions (HRRs) using secondary data from the Centers for Medicare and Medicaid Services. The relationship between HHI and OCM adoption was assessed using a 2-part regression model adjusting for the market-level number of practices, physician density, average practice size, sociodemographic characteristics, and medical resources. A count model on all HRRs was also estimated to assess an overall effect.

SUBJECTS

A total of 10,788 physicians in 3,537 practices who billed Medicare for oncology services in 2015.

RESULTS

OCM was adopted in 114 (37%) of the 306 HRRs. We found that practices in competitive health care markets were more likely to adopt OCM than in noncompetitive markets. Two-part regression analysis indicated a nonlinear relationship between HHI and OCM adoption. Average practice size, number of practices in an HRR, and the hospital bed rate were positively associated with adoption, whereas the rate of full-time equivalent hospital employees to 1000 residents was negatively associated with adoption.

CONCLUSIONS

OCM adoption was higher in HRRs with greater competition. Careful monitoring of market-level changes among OCM adopters should be undertaken to ensure that the benefits of the OCM outweigh the negative consequences of possible changes in competition.

Disruptive life event or reflexive instrument? On the regulation of hospital mergers from a quality of care perspective

PURPOSE

Despite the continuation of hospital mergers in many western countries, it is uncertain if and how hospital mergers impact the quality of care. This poses challenges for the regulation of mergers. The purpose of this paper is to understand: how regulators and hospitals frame the impact of merging on the quality and safety of care and how hospital mergers might be regulated, given their uncertain impact on quality and safety of care.

DESIGN/METHODOLOGY/APPROACH

This paper studies the regulation of hospital mergers in The Netherlands. In a qualitative study design, it draws on 30 semi-structured interviews with inspectors from the Dutch Health and Youth Care Inspectorate (Inspectorate) and respondents from three hospitals that merged between 2013 and 2015. This paper draws from literature on process-based regulation to understand how regulators can monitor hospital mergers.

FINDINGS

This paper finds that inspectors and hospital respondents frame the process of merging as potentially disruptive to daily care practices. While inspectors emphasise the dangers of merging, hospital respondents report how merging stimulated them to reflect on their care practices and how it afforded learning between hospitals. Although the Inspectorate considers mergers a risk to quality of care, their regulatory practices are hesitant.

ORIGINALITY/VALUE

This qualitative study sheds light on how merging might affect key hospital processes and daily care practices. It offers opportunities for the regulation of hospital mergers that acknowledges rather than aims to dispel the uncertain and potentially ambiguous impact of mergers on quality and safety of care.

Safely Practicing in a New Environment: A Qualitative Study to Inform Physician Onboarding Practices

BACKGROUND

Physicians are frequently asked to practice in hospitals different from their home institution, often under contracts called professional service agreements (PSAs). With highly variable onboarding processes, traveling physicians are often left to "figure out" the available resources, processes of care, crucial relationships, and culture of the new institution. This research aimed to understand the current practices of onboarding for the purpose of informing future improvements in practice.

METHODS

Two physicians conducted semistructured, in-depth interviews with physicians working at hospitals beyond their home institution. A thematic qualitative analysis was performed.

RESULTS

The sample included 20 physicians from six specialties. Key findings include (1) the basic logistics of providing care in a new environment are often not incorporated into physician onboarding and can limit physicians' ability to provide care efficiently and effectively; (2) the strength of interpersonal relationships greatly influences the ability of physicians to get help when working in new environments; and (3) managing clinical emergencies in unfamiliar settings can result in significant perceived risk to patient safety due to delays in providing care.

CONCLUSION

The onboarding process, for physicians working in new institutions, provides significant opportunity for improvement. In the future, more work is needed to ensure that the most notable differences between institutions are clarified, physicians have the necessary information and professional relationships to handle emergencies, and they know which patients they can safely care for in their new institution.

Changes in Quality of Care after Hospital Mergers and Acquisitions

BACKGROUND

The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited.

METHODS

Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership.

RESULTS

The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition.

CONCLUSIONS

Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study

OBJECTIVES

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.

METHODS

Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.

RESULTS

Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.

CONCLUSIONS

Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.

Why healthcare providers merge

In many OECD countries, healthcare sectors have become increasingly concentrated as a result of mergers. However, detailed empirical insight into why healthcare providers merge is lacking. Also, we know little about the influence of national healthcare policies on mergers. We fill this gap in the literature by conducting a survey study on mergers among 848 Dutch healthcare executives, of which 35% responded (resulting in a study sample of 239 executives). A total of 65% of the respondents was involved in at least one merger between 2005 and 2012. During this period, Dutch healthcare providers faced a number of policy changes, including increasing competition, more pressure from purchasers, growing financial risks, de-institutionalisation of long-term care and decentralisation of healthcare services to municipalities. Our empirical study shows that healthcare providers predominantly merge to improve the provision of healthcare services and to strengthen their market position. Also efficiency and financial reasons are important drivers of merger activity in healthcare. We find that motives for merger are related to changes in health policies, in particular to the increasing pressure from competitors, insurers and municipalities.