2026年9月1日 / 美国东部时间凌晨5:00 / KFF健康新闻
今年在一轮试管婴儿疗程失败后，安妮·哈格（Anne Hug）的生育医生表示，她子宫内有单个息肉，应当切除以提高受孕几率。作为放射学教授的哈格了解到，美国妇产科学院（American College of Obstetricians and Gynecologists）称该手术可在医生诊室通过局部麻醉完成。
她的医生将她转诊至同一家医院的一名医师，该医院隶属于俄亥俄州一家大型医疗系统。这名医师的方案是在医院手术室进行手术，并由麻醉医师实施麻醉。
哈格对1.8万美元的预估费用表示犹豫。
于是她找到了一名产科医生，对方表示可在诊室完成手术。她还完成了所需的为期两周的激素准备疗程。
但就在息肉切除手术的前一天，医生办公室打来电话称，抱歉，他不得不改至同医疗系统旗下的独立手术中心进行。该医疗系统于2025年收购了这家妇产科诊所，因此拥有决定权。哈格回忆称，“第二天我到了一个我根本不需要也没用过的场地，手术技术员和手术室护士忙前忙后。”
尽管安排了麻醉或镇静，她完全不想使用。医生仅对宫颈进行了麻醉，几分钟就切除了息肉，她形容“只疼了几秒钟的痉挛感”。哈格记得当时她看着息肉切除的影像，还“和手术室的工作人员聊了潜水的事”。
诊室手术的预估费用约为3000美元。而她在最后一刻被迫转至手术中心后的账单约为6000美元。她现在不禁疑惑，“当专业组织建议采用其他方式时，医院强迫患者在医院内接受手术，这怎么会是合法的？”
哈格的经历是医疗系统“纵向整合”可预见后果的典型案例：当一家公司拥有或控制供应链的多个环节，便可引导患者选择更昂贵的治疗方案。
KFF健康新闻同意不公开哈格及其医疗服务提供者的部分身份细节，以保护她的患者隐私以及她与该医院系统的现有合作关系。
无论如何，此类医疗整合正在全美以惊人的速度推进，形式多种多样：医院收购医生诊所、手术中心和影像中心；保险公司收购医生诊所、专科药房，有时还会与连锁药房合并；医院收购或创建保险公司；私募股权公司参与了众多此类交易，收购诊所、重组运营、削减成本，随后在数年后将其出售给医疗食物链上游的医院或保险公司以获利。
尽管此类整合的公开目的通常是提高效率，但研究表明，对患者而言，最终结果要么是价格更高且无益处，要么是健康状况更差。哈佛大学贝尔弗科学与国际事务中心的副教授索鲁什·萨加法ian（Soroush Saghafian）表示，这在一定程度上是因为此类收购的驱动力是财务效率，而非更无缝、贴心的护理。更重要的是，这些交易处于竞争法的灰色地带，监管机构审查或阻止此类交易的工具进展缓慢，无法胜任当前任务。
“反垄断法目前并不适用，负责执行反垄断法的机构资源不足，”耶鲁大学公共卫生与经济学副教授扎克·库珀（Zack Cooper）说道，他此前就这一趋势发出过警告。监管机构可用的工具有限——警告函、诉讼、修改合并条款以恢复竞争的同意令——而且往往需要很长时间才能取得成果。与此同时，交易仍在飞速推进。
像哈格这样的患者往往会被引导至价格更高的地点接受手术。他们实际上被要求从保险公司的专科药房或零售药房购买药品，而这些药房可能没有医生开具的药物，或以最低价格提供药物。
美国联邦贸易委员会和司法部共同监管医疗领域的合并，以保护竞争和患者选择权。通常情况下，联邦贸易委员会负责监督医院和医生，而司法部负责审查保险公司，不过两者的监管范围存在重叠，也存在漏洞。药房福利管理机构等中间商的监管则介于两者之间，但近年来联邦贸易委员会在这一领域占据了主导地位。但联邦监管机构正疲于追赶。
行业转型
在过去十年中，受雇于医院而非私人诊所的医生数量翻了一番以上。如今，82%的医生受雇于医院、其他企业实体（如保险公司）或私募股权公司。例如，联合健康集团（UnitedHealth Group）时任首席执行官在2024年表示，该集团雇佣了约1万名初级保健医生，这还不包括联合健康集团旗下8万名“附属”医生。
其中许多纵向交易规模过小，监管机构无法察觉。根据1976年的《哈特-斯科特-罗迪诺法案》，价值超过年度设定阈值（今年为1.339亿美元）的合并必须提交报告以接受反垄断审查。许多医院合并或保险公司合并都超过了这一门槛，但涉及医生诊所的合并往往达不到阈值，导致医疗行业通过缓慢积累实现整合和垄断。
库珀和他的团队——医疗保健负担得起实验室（Health Care Affordability Lab）——研究了医院收购医生诊所的案例，发现他们审查的275多笔交易中，超过99%都低于报告阈值。“我对此真的很纠结，”库珀说，“你所说的就像是一千次纸割带来的缓慢死亡。”
在特朗普总统第二任期内，联邦贸易委员会已针对医疗合并和收购提起了八起诉讼或采取了执法行动。“联邦贸易委员会已将医疗保健竞争列为我们的首要任务之一，”联邦贸易委员会竞争局局长丹尼尔·瓜尔纳拉（Daniel Guarnera）说道。不过他也表示，该机构依赖投诉和新闻报道来了解规模较小的合并交易。
司法部仅提起了两起诉讼，均针对医院与保险公司的合同，而非合并。该部门还就拜登政府试图阻止联合健康集团以33亿美元收购家庭医疗保健机构Amedisys的诉讼达成了和解。2025年的和解协议要求该公司剥离19个州的164个家庭健康和临终关怀机构。
在KFF健康新闻提出采访请求后，该部门新闻办公室通过一封未署名的邮件回复道：“您已发送邮件至司法部。请联系联邦贸易委员会的媒体团队安排采访。”后续的采访请求均未得到回复。
联邦贸易委员会的瓜尔纳拉指出，监管机构的任务是执行法规，这限制了他们可以发起的挑战。
“部分市场扭曲是由具有反竞争效果的法规造成的，”他说。
例如，无数健康政策专家都提议制定法规，强制推行“ site-neutral payment（医疗服务地点中性付费）”制度，即无论手术在哪里进行，医疗服务提供者获得的报酬都相同。这将避免哈格遭遇的困境——纵向整合的医疗系统实际上迫使医生引导患者前往更昂贵的场所接受治疗。
在政府内部，联邦贸易委员会已倡导制定新的促进竞争的法规，相关建议目前正在白宫管理和预算办公室审议中。这些建议并未公开，瓜尔纳拉也不愿透露医疗服务地点中性付费是否包含在内。与此同时，特朗普政府于7月提议为医疗保险受益人提供部分服务的地点中性付费政策。
评判纵向整合利弊的经济理论“十分复杂”，库珀说道。
评估横向整合对患者护理和成本的影响要容易得多——横向整合即医院与医院合并，或保险公司与保险公司合并。如果两家医院合并成为当地唯一的医疗服务提供商，患者的选择就会减少，新形成的垄断企业也更容易削减护理服务并提高价格。库珀说，患者“根本没办法步行去另一家医院系统就医”。
但就纵向整合而言，例如医院与保险公司和医生诊所的合并，理论上可以减少摩擦，相比每个部门都在讨价还价以最大化自身利益的分散系统，情况会更好。一些成功且广受欢迎的医院-保险公司联合体，如凯撒永久医疗集团（Kaiser Permanente），就是纵向整合的典范。库珀表示，因此单纯对这类合并采取“大锤式”的打击可能会适得其反。
但在利益驱动和商业利益主导医疗行业的情况下，研究表明纵向整合的弊端更为突出——从业者有机会利用这些有利安排牟利并提高收入。
哈佛大学的研究人员试图评估医院收购胃肠病学医生团体对结肠镜检查护理的影响，负面影响十分明显。“这改变了他们的运营方式，”该论文的主要作者萨加法ian说道。
总体而言，护理质量下降，价格和并发症发生率上升。“唯一得到改善的是‘运营吞吐量’，即系统以最少的人员投入最快地安排患者接受结肠镜检查的效率，”萨加法ian说，“这是一项财务指标。”
“感觉像是双重收费”
尽管健康经济学家正在研究其影响，以帮助监管机构确定何时采取行动，但大势已去。所有最大的健康保险公司都已与药房福利管理机构、专科和商业药房以及保险公司要求会员使用的新业务线合并，这些业务线用于管理制药公司的共付援助资金。例如：
- CVS于2018年收购了安泰保险（Aetna），这意味着安泰保险的投保人将通过其药房福利管理机构Caremark被引导至CVS专科药房。
- 信诺保险（Cigna）拥有Accredo（一家专科药房）、Express Scripts（一家药房福利管理机构）和EviCore（负责处方药申请的预先授权）。
- 联合健康集团旗下拥有Optum Rx（药房福利管理机构）、Optum专科药房和Optum输液药房。
因此，当患者更换保险公司时，他们长期以来以可预测价格获取常用药物的稳定渠道可能会戛然而止。
在佛罗里达州，阿里·H.（Ari H.）的家人因慢性病需要使用三种高价专科药物。这三种药物长期以来一直由制造商提供的患者援助计划补贴。KFF健康新闻同意仅部分公开他的身份，因为他受雇于一家政府承包商，相关政策已政治化，他担心遭到报复。
他投保了新的安泰保险计划，免赔额为3000美元，这给家庭财务带来了新的压力。在他的新计划中，他也被纳入了安泰保险的所有药房相关产品，无法选择其他渠道购药。最重要的是，他之前的保险会将共付援助资金计入免赔额，但新保险公司却不这么做，直接将制药公司提供的患者援助资金据为己有。
“我支付了高额保费，也支付了免赔额和自付最高限额——这些都是我自己承担的，”阿里·H.说道，“但现在所有的共付援助资金都落入了他们的口袋。感觉像是双重收费。”
安泰保险的发言人伊桑·斯拉文（Ethan Slavin）表示，该公司“致力于帮助会员选择最符合其健康、财务和生活方式需求的健康计划”。他补充称，该保险公司提供“可能降低自付费用的支持措施”。
阿里·H.的说法是正确的，亿万富翁投资者马克·库班（Mark Cuban）说道，他于2022年推出了Cost Plus Drugs网站，以折扣价向现金支付的患者销售大多非专利药品——价格通常低于使用保险支付的费用。“这太离谱了，”他在谈到纵向整合时说道，“左手口袋的钱给了右手口袋。”
7月，联邦贸易委员会就针对Caremark的诉讼达成和解，要求其提高透明度，给予患者和药房更多选择权。该委员会此前已与Express Scripts达成类似协议，目前正与Optum进行相关谈判。
像库珀这样的学者正试图帮助厘清“哪些纵向交易是有害的”。他表示，更清晰的经济理论可能有助于监管机构让患者的体验“稍微好那么一点”。
KFF健康新闻是一家全国性新闻编辑部，专注于健康问题深度报道，是KFF的核心运营项目之一——KFF是独立的健康政策研究、民意调查和新闻资讯来源。
The market forces quietly adding thousands to patient bills
September 1, 2026 / 5:00 AM EDT / KFF Health News
After a failed round of IVF this year, Anne Hug’s fertility doctor said she had a single polyp in her uterus that should be removed to improve the chance of pregnancy. Hug, a professor of radiology, learned that the American College of Obstetricians and Gynecologists says the procedure can be done in a doctor’s office with local numbing.
Her doctor referred her to a physician at the same hospital, which is part of a large Ohio health system. That doctor’s plan was to do the procedure in a hospital operating room, with anesthesia administered by an anesthesiologist.
Hug balked at the $18,000 estimate.
So she found an obstetrician who said he would do it in the doctor’s office. And she took the required two-week course of a hormone in preparation.
But the day before the polyp removal, the doctor’s office called to say, sorry, but he had to do it in a freestanding surgery center owned by the same system. The health system had bought the OB-GYN practice in 2025, so it called the shots. The next day, Hug recalled, “I’m in a venue I didn’t need or use, with surgical techs and OR nurses running around.”
Though she was scheduled for anesthesia or sedation, she wanted none of it. The doctor numbed the cervix and removed the polyp in a few minutes, with “a few seconds of cramping,” she said. Hug remembers watching pictures of the polyp removal and “talking to the OR crew about snorkeling.”
The estimate for the in-office procedure was around $3,000. The bill when she was forced at the last minute to switch to the surgery center was around $6,000. She now wonders, “How is it legal for these hospitals to force patients to have procedures done in a hospital when professional organizations recommend differently?”
Hug’s experience is a classic example of the predicted outcome of “vertical integration” in the healthcare system, when one company owns or controls multiple parts of a supply chain and can therefore direct patients to more expensive treatment options.
KFF Health News agreed not to publish some identifying details about Hug and her healthcare providers, to protect her patient privacy and ongoing relationship with the hospital system.
In any case, such healthcare integration is occurring at a breakneck pace all across the nation, with endless permutations: Hospitals are buying doctors’ practices and surgery and imaging centers. Insurers are buying doctors’ practices and specialty pharmacies and sometimes merging with pharmacy chains. Hospitals are buying or creating insurers. Private equity firms are behind many of the deals, buying practices, reorganizing operations, paring costs, then selling at a profit in a few years to a hospital or insurer higher up the healthcare food chain.
And while the stated purpose is generally greater efficiency, studies have shown that for patients the net result has been higher prices and no benefit, or worse health outcomes. That’s in part because the purchases have been driven by financial efficiency, not more seamless and attentive care, said Soroush Saghafian, an associate professor at Harvard University’s Belfer Center for Science and International Affairs. What’s more, these transactions occur in a gray zone of competition law, and regulators’ tools to examine or stop them are plodding and not up to the task.
“Antitrust laws aren’t fit for purpose at this point, and the agencies that enforce them are under-resourced,” said Zack Cooper, an associate professor of public health and economics at Yale University who has sounded the alarm about the trend. The tools at the agencies’ disposal are limited — warning letters, lawsuits, and consent decrees modifying the terms of a merger to restore competition — and often slow to get results. Meanwhile, the dealmaking is galloping ahead.
Patients like Hug are often directed to a higher-priced location for procedures. They are effectively required to buy from their insurers’ specialty or retail pharmacy, which may not stock the drug the doctor prescribes or provide it at the lowest price.
The Federal Trade Commission and the Justice Department together police mergers in healthcare to protect competition and patient choice. Generally, the FTC oversees hospitals and doctors, while the Justice Department scrutinizes insurers, though their territories overlap and there are gaps. Middlemen like pharmacy benefit managers fall somewhere in between, though in recent years the FTC has taken the lead in this arena. But federal regulators are playing a tough game of catch-up.
Industry shift
Over the past decade, the number of doctors working for hospitals rather than in private practice has more than doubled. Today 82% of physicians are employed by hospitals, other corporate entities (like insurers), or private equity firms. For example, UnitedHealth Group’s then-CEO said in 2024 that it employed around 10,000 primary care physicians. That did not include UnitedHealth’s 80,000 “affiliated” physicians.
Many of these vertical transactions are too small for the regulatory agencies to spot. Under the 1976 Hart-Scott-Rodino Act, mergers valued over a certain dollar threshold set annually — this year it’s $133.9 million — must be reported for antitrust scrutiny. Many hospital mergers or insurer mergers exceed the threshold. But mergers involving doctors’ practices often do not, leading to consolidation and monopoly by slow accretion.
Cooper and his group, the Health Care Affordability Lab, studied hospital acquisitions of physician practices and found that over 99% of the more than 275 deals examined fell below the reporting threshold. “I’m really struggling with this,” Cooper said. “What you’re talking about is sort of like death by a thousand paper cuts.”
The FTC has brought eight actions or suits against healthcare mergers and acquisitions in President Trump’s second term. “The FTC has made healthcare competition one of our top priorities,” said Daniel Guarnera, director of the FTC’s Bureau of Competition. Nonetheless, he said the agency relied on complaints and news reports to learn about smaller mergers.
The Justice Department has brought only two cases, both challenging hospital-insurer contracts rather than mergers. It has also settled a suit brought by the Biden administration that sought to block UnitedHealth’s $3.3 billion acquisition of Amedisys, a home healthcare agency. The 2025 settlement required the divestiture of 164 home health and hospice locations across 19 states.
After KFF Health News requested an interview, the department’s press office replied in an unsigned email: “You’ve emailed the Department of Justice. Please reach out to FTC’s media team to set up an interview.” Further requests went unanswered.
Guarnera, at the FTC, noted that the agencies’ task is to enforce regulations, limiting the challenges they can bring.
“Some of the market distortion is caused by regulations that have anticompetitive effects,” he said.
For example countless health policy experts have proposed regulations mandating “site-neutral payment,” a system in which providers would get the same amount for a procedure no matter where it was performed. That would prevent predicaments like Hug’s, in which a vertically integrated system effectively backs doctors into directing patients to a more expensive venue for treatment.
Within the government, the FTC has advocated for new pro-competitive regulations, suggestions that are now under review by the White House’s Office of Management and Budget. They are not public, and Guarnera wouldn’t say whether site-neutral payment is included. Meanwhile, the Trump administration in July proposed instituting site-neutral payments for some services for Medicare beneficiaries.
The economic theory adjudicating the pros and cons of vertical integration is “nuanced,” Cooper said.
It is far easier to assess the effects of horizontal integration — when a hospital merges with a hospital or an insurer with an insurer — on patient care and cost. If two hospitals merge and become the only care provider in town, that leaves patients with less choice and can make it easier for the new monopoly to skimp on care and raise prices. There is no way “to walk with your feet” to another hospital system for care, Cooper said.
But with vertical integration, for example, a hospital merger with an insurer and doctors’ practices could in theory diminish friction, compared with a disaggregated system in which every bill is haggled over by different sectors trying to maximize their piece of the pie. Some successful and popular hospital-insurer combinations, such as Kaiser Permanente, are vertically integrated. So merely taking a “sledgehammer” to such mergers could backfire, Cooper said.
But with money on the table and business interests governing healthcare, studies have shown that cons of vertical integration — the opportunity for gaming away those beneficial arrangements and raising revenue — prevail.
When Harvard researchers sought to assess the effect of hospital purchases of gastroenterology physician groups on colonoscopy care, the negative impact was clear. “It changed the way they did business,” said Saghafian, the paper’s main author.
All told, quality went down and prices as well as complication rates rose. “What improves is ‘operational throughput,’” or the efficiency with which the system could move patients through colonoscopies fastest with the least staff involvement, Saghafian said. “That’s a financial metric.”
“It feels like double-dipping”
While health economists are studying the impacts to help regulators figure out when to act, the horse is out of the barn. All the biggest health insurers have already merged with pharmacy benefit managers, specialty and commercial pharmacies, as well as new lines of businesses that insurers require members to use to manage copay assistance from pharmaceutical companies. For example:
- CVS acquired Aetna in 2018, meaning Aetna subscribers are directed to the CVS Specialty pharmacy through Caremark, its pharmacy benefit manager.
- Cigna owns Accredo (a specialty pharmacy), Express Scripts (a pharmacy benefit manager), and EviCore (which does preauthorization for prescription requests).
- UnitedHealth includes Optum Rx (a pharmacy benefit manager), Optum Specialty Pharmacy, and Optum Infusion Pharmacy.
So when patients change insurers, their steady access to longtime drugs at a predictable price can go out the door.
In Florida, Ari H.’s family uses three high-priced specialty drugs for chronic conditions. All three had long been subsidized by patient assistance programs from their manufacturers. KFF Health News agreed to only partially identify him, because he works for a government contractor where policy has become political and he fears retaliation.
Signing up for a $3,000-deductible plan with a new insurer, Aetna, put a new strain on his family’s finances. On his new plan, he was signed up for all Aetna’s pharmacy-related products, too. He could not choose to order elsewhere. Most importantly, his old insurance counted the copay assistance money toward his deductible, but his new insurer did not, scooping up his patient assistance money from pharmaceutical firms.
“I pay substantial premiums, and I pay my deductible and my out-of-pocket maximum — that’s all paid by me,” Ari H. said. “But now all the copay assistance goes back to them. It feels like double-dipping.”
Ethan Slavin, an Aetna spokesperson, said the company “is committed to helping members choose and use health plans that best meet their health, financial, and lifestyle needs.” He added that the insurer offers “supports that may lower out-of-pocket expenses.”
Ari H. is right, said Mark Cuban, the billionaire investor who in 2022 launched the Cost Plus Drugs site, which sells mostly generic drugs to cash-paying patients at a discount — often for less than what they would pay using insurance. “It’s crazy stuff,” he said of vertical integration. “The right pocket gives to the left pocket.”
In July the FTC reached a settlement in a suit against Caremark, requiring it to be more transparent and give patients and pharmacies more choice. It had previously reached such an agreement with Express Scripts and is working on one with Optum.
Academics like Cooper are trying to help clarify “which of these vertical deals are bad.” A clearer economic theory, he said, might help regulators make the patient experience just “a little less worse.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.