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How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry


  • Paul J Eliason
  • Benjamin Heebsh
  • Ryan C McDevitt
  • James W Roberts


Many industries have become increasingly concentrated through mergers and acquisitions, which in health care may have important consequences for spending and outcomes. Using a rich panel of Medicare claims data for nearly one million dialysis patients, we advance the literature on the effects of mergers and acquisitions by studying the precise ways providers change their behavior following an acquisition. We base our empirical analysis on more than 1,200 acquisitions of independent dialysis facilities by large chains over a 12-year period and find that chains transfer several prominent strategies to the facilities they acquire. Most notably, acquired facilities converge to the behavior of their new parent companies by increasing patients’ doses of highly reimbursed drugs, replacing high-skill nurses with less-skilled technicians, and waitlisting fewer patients for kidney transplants. We then show that patients fare worse as a result of these changes: outcomes such as hospitalizations and mortality deteriorate, with our long panel allowing us to identify these effects from within-facility or within-patient variation around the acquisitions. Because overall Medicare spending increases at acquired facilities, mostly as a result of higher drug reimbursements, this decline in quality corresponds to a decline in value for payers. We conclude the article by considering the channels through which acquisitions produce such large changes in provider behavior and outcomes, finding that increased market power cannot explain the decline in quality. Rather, the adoption of the acquiring firm’s strategies and practices drives our main results, with greater economies of scale for drug purchasing responsible for more than half of the change in profits following an acquisition.

Suggested Citation

  • Paul J Eliason & Benjamin Heebsh & Ryan C McDevitt & James W Roberts, 2020. "How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 135(1), pages 221-267.
  • Handle: RePEc:oup:qjecon:v:135:y:2020:i:1:p:221-267.

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    Cited by:

    1. Martin Gaynor & Kate Ho & Robert J. Town, 2015. "The Industrial Organization of Health-Care Markets," Journal of Economic Literature, American Economic Association, vol. 53(2), pages 235-284, June.
    2. Tarantino, Emanuele & Pavanini, Nicola & Mayordomo, Sergio, 2020. "The Impact of Alternative Forms of Bank Consolidation on Credit Supply and Financial Stability," CEPR Discussion Papers 15069, C.E.P.R. Discussion Papers.
    3. Nikhil Agarwal & Paulo J. Somaini, 2022. "Demand Analysis under Latent Choice Constraints," NBER Working Papers 29993, National Bureau of Economic Research, Inc.
    4. Ambar La Forgia, 2023. "The Impact of Management on Clinical Performance: Evidence from Physician Practice Management Companies," Management Science, INFORMS, vol. 69(8), pages 4646-4667, August.
    5. Ivan Badinski & Amy Finkelstein & Matthew Gentzkow & Peter Hull, 2023. "Geographic Variation in Healthcare Utilization: The Role of Physicians," NBER Working Papers 31749, National Bureau of Economic Research, Inc.
    6. Brendon McConnell, 2023. "What's Logs Got to do With it: On the Perils of log Dependent Variables and Difference-in-Differences," Papers 2308.00167,, revised Aug 2023.
    7. Chiara Fumagalli & Massimo Motta & Emanuele Tarantino, 2020. "Shelving or developing? The acquisition of potential competitors under financial constraints," Economics Working Papers 1735, Department of Economics and Business, Universitat Pompeu Fabra.
    8. Aaron Barkley, 2023. "The Human Cost of Collusion: Health Effects of a Mexican Insulin Cartel," Journal of the European Economic Association, European Economic Association, vol. 21(5), pages 1865-1904.
    9. Andy Ye Yuan & Bernard Black & Timea Viragh & David J. Magid & Qian Luo & Ali Moghtaderi, 2023. "Effect of financial incentives on hospital‐cardiologist integration and cardiac test location," Journal of Empirical Legal Studies, John Wiley & Sons, vol. 20(3), pages 570-608, September.
    10. Robert Clark & Mario Samano, 2022. "Incentivized Mergers and Cost Efficiency: Evidence from the Electricity Distribution Industry," Journal of Industrial Economics, Wiley Blackwell, vol. 70(4), pages 791-837, December.
    11. Haucap, Justus & Stiebale, Joel, 2023. "Non-price effects of mergers and acquisitions," DICE Discussion Papers 402, Heinrich Heine University Düsseldorf, Düsseldorf Institute for Competition Economics (DICE).
    12. Petek, Nathan, 2022. "The marginal benefit of hospitals: Evidence from the effect of entry and exit on utilization and mortality rates," Journal of Health Economics, Elsevier, vol. 86(C).
    13. Atul Gupta & Sabrina T Howell & Constantine Yannelis & Abhinav Gupta, 2021. "Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes," Working Papers 2021-20, Becker Friedman Institute for Research In Economics.
    14. Russ Kashian & Nicholas Lovett & Yuhan Xue, 2020. "Has the affordable care act affected health care efficiency?," Journal of Regulatory Economics, Springer, vol. 58(2), pages 193-233, December.

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