- Three-quarters of metropolitan statistical areas had a highly concentrated commercial health insurance market in 2018, according to a new report from the American Medical Association. The percentage of such markets increased from 71% in 2014.
- The payer with the highest market share in the most metro areas was Anthem with 77 MSAs, followed by Health Care Service Corp. (42), UnitedHealth Group (27), Florida Blue (22) and Highmark (21).
- AMA released the study Tuesday, the same day the Health Care Cost Institute put out new research highlighting similar numbers of highly concentrated hospital markets between 2012 and 2016. That report also showed a correlation to increasing prices as markets became more concentrated.
Provider and payer groups are ratcheting up arguments over who to blame for increasing healthcare costs as issues like surprise billing and price transparency gain scrutiny from lawmakers, and Democratic presidential contenders debate "Medicare for All" policies.
The fight is an extension of the finger pointing over the country's massive healthcare bill, expected to reach nearly 20% of the U.S. economy by 2027.
What's clear is that rampant M&A activity and consolidation in both sectors has led to fewer players, higher prices and patients stuck in the middle. Major mergers in the payer space include Centene's $17 billion buy of rival WellCare, which is still going through regulatory approval.
But in recent years, some major payer mergers — such as Anthem's attempt to acquire Cigna and Aetna's plan to buy Humana, both in 2017 — have been stymied by federal regulators. Cigna did move forward with its $67 billion acquisition of pharmacy benefit management company Express Scripts in 2018, however.
Regulators share some of these concerns with vertical megamergers, mostly notably the CVS-Aetna deal. The companies' merger settlement agreement with the Department of Justice, which AMA opposed, finally got approval from a federal judge earlier this month, but the review itself was unprecedented.
The larger battle is mirrored in smaller squabbles throughout the country over rate setting. This month, a spat between a Massachusetts health system and the local Blue Cross Clue Shield plan spilled out into the public as the two negotiate a new contract. Another Blues system, Highmark, reached an agreement with UPMC in June after more than four months of vocal disagreements.
The AMA study is intended to help researchers, regulators and policymakers find markets "where future consolidation among health insurers may cause competitive harm to patients," the group said in a press release.
"These markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care. Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers between health insurers," according to the report.
Asked for comment on the findings, America's Health Insurance Plans pointed to the HCCI report and other research on provider consolidation tracking with higher prices. "In fact, people living in these highly consolidated hospital markets pay significantly higher premiums than residents in markets that have less provider consolidation," AHIP said. "When providers consolidate and gain more market power, they have an incentive to demand higher prices."
AMA found that, in more than 90% of markets, at least one insurer had a 30% or greater market share and in nearly half of the markets a single payer had at least a 50% share. More than half of the metros that were already highly concentrated in 2014 became more concentrated and 27% were converted to highly concentrated over that time period.
The states with the least competitive markets were Alabama, Louisiana, Hawaii, Delaware and South Carolina. The largest increases in competition were found in Utah, Louisiana, Florida, New Hampshire and Alabama.
Both the AMA and HCCI study evaluate market concentration using the Herfindahl-Hirschman Indices and define "highly concentrated" using DOJ guidelines.