Consequences of Hospital Closures for the Health Insurance Industry in the United States

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Author

Congratulation on your valued work. I read it thoroughly and while I enjoyed it a lot I had some comments you may find them useful:

1- While your MS is special and using your own keywords is not an odd thing, you may consider selecting some of them from a system like MeSH, so that other researchers could find your MS more easily when they search is scholar databases. 

2- The method you have used for inserting citations and references is a little bit confusing and reader may get them wrong with another number. Please put them in the middle of parenthesis or other standard type of references. 

3- The perspective was of great importance, both for the hospitals and for the insurance companies. However, I think it is useful to mention the role of the primary healthcare (PHC) for improving health level of the people and their health promotion and beside that, disease prevention. These two steps could be led by authorities of ministry of health and also by insurance companies using incentive plans for the policy holders and also for hospitals. This could lead to a serious decrease in the people attending to a hospital for expensive curative treatments. Instead they could live a healthier life. This also will help insurance companies to receive premiums form healthier people while they do not have to spend it and even have extra cost for ACA. 

4- You may mention the fact that unlike any other service or good, health is  a complex service. The healthcare interventions could be induced b the hospitals and the physicians and healthcare practitioners, which could lead to overuse of healthcare. On the other hand, it could be variate from its original  purpose and the case of underuse could happen. The misuse, overuse and underuse of healthcare interventions could harm the population health, lead to hospital closure and the bankruptcy of insurance companies. 

5- The unique role of stewardship which should be implied by ministry of health is necessary for increasing proper use of healthcare interventions. 

6- Regionalization of healthcare facilities and levels of cares (1- health promotion, 2-disease prevention, 3-curative, - rehabilitation and 5-palliative) are important according to WHO which I think should be mentioned in this article. 

Good luck. 

Comments for author File: Comments.pdf

Author Response

Reviewer 1:

1- While your MS is special and using your own keywords is not an odd thing, you may consider selecting some of them from a system like MeSH, so that other researchers could find your MS more easily when they search is scholar databases.

The keywords were revised using the MeSH system and now also include “Health facility closure, Hospital economics, and Access to health care”

2- The method you have used for inserting citations and references is a little bit confusing and reader may get them wrong with another number. Please put them in the middle of parenthesis or other standard type of references. 

Response: In the original and submitted version of the manuscript all references were superscript. Since the publisher's transcription to the reviewers eliminated all superscript notations, parentheses are now added for the reference numbers.

3- The perspective was of great importance, both for the hospitals and for the insurance companies. However, I think it is useful to mention the role of the primary healthcare (PHC) for improving health level of the people and their health promotion and beside that, disease prevention. These two steps could be led by authorities of ministry of health and also by insurance companies using incentive plans for the policy holders and also for hospitals. This could lead to a serious decrease in the people attending to a hospital for expensive curative treatments. Instead they could live a healthier life. This also will help insurance companies to receive premiums form healthier people while they do not have to spend it and even have extra cost for ACA. 

Response: This is a valid and interesting consideration but beyond the scope of this perspective. Better health promotion by strengthening the role of primary healthcare, as suggested by the reviewer, could indeed lead to an overall reduction in hospital beds and insurance payments. However, and in contrast to the predominantly privately-funded healthcare system in the US, such stipulations are much easier implemented in a publicly-funded system like the NHS. This perspective focuses on hospitals in the US that are currently struggling; incentive plans and disease prevention to reduce hospitals are important but different topics.

4- You may mention the fact that unlike any other service or good, health is  a complex service. The healthcare interventions could be induced b the hospitals and the physicians and healthcare practitioners, which could lead to overuse of healthcare. On the other hand, it could be variate from its original  purpose and the case of underuse could happen. The misuse, overuse and underuse of healthcare interventions could harm the population health, lead to hospital closure and the bankruptcy of insurance companies. 

Response: The reviewer is absolutely correct in that health is a complex service and that there is a risk of overuse. However, when it comes to hospital admissions and costly treatment plans, insurance companies in the US much more frequently than, for example, in European countries deny services. The recent, unfortunate assassination of the United Health CEO brought this topic to the forefront of the discussion.

The misuse of healthcare interventions, as suggested by the reviewer is now mentioned on page 2, #2.

5- The unique role of stewardship which should be implied by ministry of health is necessary for increasing proper use of healthcare interventions.

As the reviewer is probably keenly aware, the “ministry of health”, i.e. HHS, does not oversee proper use of healthcare interventions in the US, except for the relatively small VA system. This is clearly a disadvantage of the US healthcare system in contrast to the Canadian and British systems.

6- Regionalization of healthcare facilities and levels of cares (1- health promotion, 2-disease prevention, 3-curative, - rehabilitation and 5-palliative) are important according to WHO which I think should be mentioned in this article.

This consideration is now addressed on page 4, #3:

“Unlike in primarily publicly-funded healthcare systems like in Canada and the UK, governmental interventions at the state or federal level concerning potential hospital closures basically do not occur in the US due to its primarily privately-funded healthcare system. Hence, a master plan for regionalization of healthcare facilities to absorb hospital closures and to guarantee continued levels of care does not exist.”

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

1.   Various numbers for hospital closures and at-risk hospitals are cited in the passage (e.g., 40 in 2022, 23 by November 2024, 600 at danger, 700 at risk). Could the author clarify the methodology and sources used to arrive at these disparate figures to guarantee accuracy and consistency? Do these figures reflect distinct categories (e.g., closures vs. at risk), or are they mutually exclusive?

2. According to the passage, 186 rural hospitals closed between 2005 and 2022. To illustrate changes over time, might the author include a year-by-year breakdown or a more detailed study of this data?

3. According to CHQPR, 600 rural hospitals could shut down in 2023. The text notes that 700 rural hospitals were also in danger of closing. They come from numerous sources. Could the author elaborate on the variations in these figures and the range of evaluations from each source?

4. According to the text, The AHA reported 6,129 hospitals in the United States in 2023. Does this figure align with data from other sources? If there are any inconsistencies, may the author briefly address them?

5. The text enumerates several reasons why hospitals close. Are any of these elements just correlations, or does the author aim to suggest a causal link between these characteristics and closures? Could the author detail the relative significance of each aspect by citing research or other proof of their influence?

6. According to the paragraph, recent hospital closures have been "majorly impacted" by economic factors. Could the author provide concrete instances of how these pressures have resulted in closures or quantify this impact?

7. The ACA is mentioned as a contributing element in the passing. Could the author elaborate on the ACA mandates that put hospitals under financial strain? Does this association directly impact, or do other factors mediate it?

8. According to the paragraph, little about how hospital closures affect the health insurance sector is known. However, the main topic of the remainder of the section is the effect on hospitals, patients, and communities. Could the author either elaborate on the impact on insurance firms or modify the introduction to more accurately represent the topic and clarify the paper's intended scope?

9. The phrase "hospital consolidations" is used in the paragraph to refer to hospital closures in a "deceptively positive" way. Could the author clarify how these two concepts differ and why "consolidation" can be seen as misleading?

10. The US setting is the main emphasis of the paragraph. Could the author briefly address whether other nations with comparable healthcare systems exhibit these patterns and contributing factors?

11. "Unwinding of the Medicaid continuous Patient Protection and Affordable Care Act (ACA) enrollment" is used in the text. Could the author elaborate on the nature of this "unwinding" and how it leads to hospital closures?

12. "Unfavorable payer contracts" are mentioned in the paragraph, although it is unclear what exactly makes them such. Could the author elaborate on the features of these contracts?

 

 

Comments on the Quality of English Language

The study could be expressed more clearly with a correction in English. 

Author Response

1. Various numbers for hospital closures and at-risk hospitals are cited in the passage (e.g., 40 in 2022, 23 by November 2024, 600 at danger, 700 at risk). Could the author clarify the methodology and sources used to arrive at these disparate figures to guarantee accuracy and consistency? Do these figures reflect distinct categories (e.g., closures vs. at risk), or are they mutually exclusive?

Response: The following text was added for clarification (page 1, #2}: “A limiting factor in analyzing hospital closures in the United States is the fact that a single, dedicated "hospital closure database" does not exist. Comprehensive information on hospital closures can only be accessed by combining data from different sources, including the Centers for Medicare & Medicaid Services (CMS) Online Survey Certification and Reporting (OSCAR) system, the American Hospital Association (AHA), and state-level hospital databases.”

Hence and as stated in the text, multiple source citations were used to most accurately present available data. The slightly disparate figures of “600 at danger, 700 at risk” is based on 2 different, reliable sources and the figures are within the same range. “Closures vs. at risk” are different entities and mutually exclusive.

2. According to the passage, 186 rural hospitals closed between 2005 and 2022. To illustrate changes over time, might the author include a year-by-year breakdown or a more detailed study of this data?

Response: Unfortunately, a breakdown of rural hospitals by year has not been published in the available literature.

3. According to CHQPR, 600 rural hospitals could shut down in 2023. The text notes that 700 rural hospitals were also in danger of closing. They come from numerous sources. Could the author elaborate on the variations in these figures and the range of evaluations from each source?

Response: The text was reworded for further clarification: “A 2023 analysis of the financial vulnerability of rural hospitals by the Center for Healthcare Quality and Payment Reform (CHQPR) showed that 600 rural hospitals were at risk of closing. The most common risks were persistent financial challenges related to patient services or depleted financial resources. [8] A Beckers Healthcare report came to a similar conclusion by stating that in 2023, about 700 rural hospitals faced the continued risk of closing due to serious financial challenges. [9]”

4. According to the text, The AHA reported 6,129 hospitals in the United States in 2023. Does this figure align with data from other sources? If there are any inconsistencies, may the author briefly address them?

Response: The AHA is the most reliable source in the: “As the national voice and advocate for the nation’s hospitals and health systems, the American Hospital Association is committed to providing hospital statistics like this and data to support the field, including its annual survey of hospitals in the United States”

5. The text enumerates several reasons why hospitals close. Are any of these elements just correlations, or does the author aim to suggest a causal link between these characteristics and closures? Could the author detail the relative significance of each aspect by citing research or other proof of their influence?

Response: As the reviewer is aware, the reasons for hospital closures are complex and usually not the result of one cause only. There are causal links between the various reasons, for example between strained finances and, unfortunately, quality and access constraints.

The text was expanded accordingly on page 2, #2: There are many reasons and correlations with causal links why hospitals and health systems find themselves in distress. [10]  

6. According to the paragraph, recent hospital closures have been "majorly impacted" by economic factors. Could the author provide concrete instances of how these pressures have resulted in closures or quantify this impact?

Response: The text was expanded as follows: “Particularly the COVID-19 pandemic has significantly contributed to hospital closures [8-12] by causing a (1) sharp decline in patient volume due to cancelled elective surgeries and (2) increased costs associated with treating very sick COVID patients.”

7. The ACA is mentioned as a contributing element in the passing. Could the author elaborate on the ACA mandates that put hospitals under financial strain? Does this association directly impact, or do other factors mediate it?

Response: Per the reviewer’s suggestion, the text was expanded as follows: “Moreover, in the past, Medicare and Medicaid disproportionate share hospital (DSH) payments provided significant financial relief to safety-net hospitals. But the ACA mandates a sizeable reduction in DSH payments which pushes primarily safety-net hospitals directly to the brink of bankruptcy. [14]” (Page 2, #5)

8. According to the paragraph, little about how hospital closures affect the health insurance sector is known. However, the main topic of the remainder of the section is the effect on hospitals, patients, and communities. Could the author either elaborate on the impact on insurance firms or modify the introduction to more accurately represent the topic and clarify the paper's intended scope?

Response: The impact of hospital closures on insurance firms is covered on page 3, ##3-8 with expansion as per the suggestions of all 3 reviewers.

9. The phrase "hospital consolidations" is used in the paragraph to refer to hospital closures in a "deceptively positive" way. Could the author clarify how these two concepts differ and why "consolidation" can be seen as misleading?

Response: As stated, hospital closures are sometimes sold to constituents by policymakers/politicians or to consumers by insurance companies as positive business consolidations which falsely implies to the uninformed citizen prudent and reasonable  measures of potential cost-saving and redundancy reduction whereas, in the healthcare sector, it leads to both reduced access and lower quality of care.

10. The US setting is the main emphasis of the paragraph. Could the author briefly address whether other nations with comparable healthcare systems exhibit these patterns and contributing factors?

Response: From the global perspective, this issue is an important topic. However, it goes beyond the scope of this perspective which focuses on the US only. The US health system (for better or worse) is unique and cannot be directly compared to more publicly funded health systems like in Canada or the UK where the government has a much greater impact/say on hospital closures.

11. "Unwinding of the Medicaid continuous Patient Protection and Affordable Care Act (ACA) enrollment" is used in the text. Could the author elaborate on the nature of this "unwinding" and how it leads to hospital closures?

Response: The unwinding of Medicaid's continuous enrollment describes the process by which states resume disenrolling and redetermining Medicaid eligibility. As a result, some people will lose their Medicaid coverage.

In addition to “unwinding”, “loss” is now added to the text.

12. "Unfavorable payer contracts" are mentioned in the paragraph, although it is unclear what exactly makes them such. Could the author elaborate on the features of these contracts?

Response: Examples of unfavorable payer contracts are now provided: “extensive bundling, electronic payment requirements through third parties, policy changes, annual escalators, specialty pharmacy requirements” (Page 2, #1).

Reviewer 3 Report

Comments and Suggestions for Authors

Recommendations to the author: 

The article is well documented, but you could have discussed in more detail the differences between the impact of rural and urban hospital closures on the insurance system. 

You clearly presented the need for cooperation between the insurance industry and hospitals.

The author's conclusions are convincing, and the proposed solutions, such as improving payment systems, are practical and worth considering - here I recommend expanding and highlighting these threads. 

The author of the article is a valuable contribution to the discussion on improving the sustainability of the US healthcare system so to highlight this more strongly I suggest:

You could have better considered regional differences and the impact of health policy on hospital closures. 

I would like you to consider more examples of effective strategies to prevent hospital closures.

Author Response

The article is well documented, but you could have discussed in more detail the differences between the impact of rural and urban hospital closures on the insurance system. 

Response: The following was added to differences between the impact of rural and urban hospital closures on the insurance system (page 3, #1): "Hence, both rural and urban hospital closures can lead to increased costs for commercially insured patients because patients are often forced to seek care at more expensive facilities or due to a smaller pool of available providers in the area."

You clearly presented the need for cooperation between the insurance industry and hospitals.

Response: n/a

The author's conclusions are convincing, and the proposed solutions, such as improving payment systems, are practical and worth considering - here I recommend expanding and highlighting these threads.

Response: The additional (positive) impact of higher Medicare and Medicaid reimbursement rates for hospitals in rural communities further expands now on the proposed solutions (page 4, #6).

The author of the article is a valuable contribution to the discussion on improving the sustainability of the US healthcare system so to highlight this more strongly I suggest:

Response: The fact that the proposed measures may help to improve the sustainability of the US healthcare system is now mentioned in the abstract und the summary section (page 4, #7).

You could have better considered regional differences and the impact of health policy on hospital closures. 

Response: As suggested by the reviewer, the following was added: "Hospital closures in rural areas are often the result of regional differences due to demographics, population density and access to healthcare" (page 2, #5) and "In addition, more balanced federal and state health policies such as higher Medicare and Medicaid reimbursement rates for rural hospitals can positively impact their financial stability since rural hospitals have a higher reliance on public payers. Specifically on the state level, policymakers can appropriate more funds to facilities and providers. Such changes in health policy have the potential to reduce the risk of hospital closures in rural communities." (page 4, #6) 

I would like you to consider more examples of effective strategies to prevent hospital closures.

Response: Effective strategies to prevent hospital closures on page 4, ##4-6, were expanded as suggested.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Author

Thanks for your efforts to address my comments. I think the responses were fair and adequate. I could add nothing more. Good luck.