Spurred in part by the Affordable Care Act, hospitals across the country have merged to form massive medical systems in the belief it would simplify the process for patients.
But a simpler bill doesn't always guarantee a cheaper bill.
That's a key issue in an antitrust lawsuit against one of California's largest hospital systems set to begin Monday.
About 1,500 self-funded health plans have sued Sutter Health, a system that includes 24 hospitals across Northern California. The case has dragged on since 2014, but it picked up steam last year when Attorney General Xavier Becerra filed a similar lawsuit. The cases have been combined and jury selection begins Monday. Opening arguments are scheduled for October.
The lawsuit alleges Sutter Health gobbled up competing medical providers in the region and used its market dominance to set higher prices for insurance plans, which means more expensive insurance premiums for consumers.
Becerra points to a 2018 study that found unadjusted inpatient procedure prices are 70% higher in Northern California than Southern California. The lawsuit notes Sutter Health's assets were $15.6 billion at the end of 2016, up from $6.4 billion in 2005.
"We never meant for folks to use integration to boost their profits at the expense of consumers," Becerra said.
It's rare for antitrust lawsuits of this size to go to trial because the law allows for triple damages — a prospect that often spooks companies into settling outside of court to avoid an unpredictable jury. Health plans in this case are asking for $900 million in damages, meaning Sutter Health could take a nearly $3 billion hit.
Atrium Health, a North Carolina-based hospital system, settled a similar anti-trust lawsuit with the federal government last year. And CHI Franciscan, a health system based in Washington state, also settled similar claims in March that had been brought by the state.
But Sutter Health is fighting the case. The company says the lawsuit is not about its prices, but about insurance companies who want to maximize their own profits. Sutter Health officials insist the company faces fierce competition, vowing to detail in court the expansion of other health systems in the San Francisco Bay Area and the Sacramento Valley.
Four Sutter Health hospitals had operating losses in 2018, totaling $49 million.
"The bottom line is that this lawsuit is designed to skew the healthcare system to the advantage of large insurance companies so they can market inadequate insurance plans to Californians," said Sutter Health Director of Public Affairs Amy Thoma Tan.
At issue are several of Sutter Health's contracting policies that Becerra says have allowed the company to "thoroughly immunize itself from price competition."
One way insurance companies keep costs down is to steer patients to cheaper health care providers through a variety of incentives. Becerra says Sutter Health bans insurance companies from using these incentives, making it harder for patients to use their lower-priced competitors.
Becerra also says Sutter has an "all or nothing" approach to negotiating with insurance companies, requiring them to include all of the company's hospitals in their provider networks even if it doesn't make financial sense to do so.
The case was originally filed by a trust of Northern California's largest unionized grocery companies in 2014. A representative for the trust said it was "unknowingly forced to pay Sutter's artificially high prices."
But the company says these contracting practices are designed to protect patients. People often are unable to pick which hospital they go to in a medical emergency, which can lead to surprise bills when they learn a hospital or doctor was not in their network.
Jackie Garman, lawyer for the California Hospital Association, said these contracting practices are standard at a lot of hospitals. If the lawsuit is successful, she said it could "disrupt contracting practices at a lot of other systems."
But the consequences of not bringing the lawsuit could be greater, Becerra said.
"We are paying every time we allow an anti-competitive behavior to drive the market," he said.