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WHY IS THIS HAPPENING? Hospitals, already under intense pressure to lower costs and improve care, have been losing patients. More and more surgeries are performed in clinics and

doctors' offices, so the patient doesn't spend the night in the hospital. The recession also cut the number of hospital patients as people put off treatment, according to Caroline

Steinberg, a vice president with the American Hospital Association. Left with too many empty beds, hospitals again began to consolidate with hospitals and doctors in 2010. (Hospitals that

hire physicians see an increase in patients, who come to see their doctors for everything from tests to outpatient surgeries.) "The logo on the front of the hospital might change, but

as long as your doctor has privileges there, ownership may not matter much." Proponents of the Affordable Care Act, which is bringing millions of new patients into the health care

system and into hospitals, say it aims to promote competition and lower the costs of care. To rein in health care costs, however, the law reduces the rate of growth in Medicare payments to

hospitals. And importantly, it also provides incentives for hospitals to hire or form more partnerships with doctors' practices and other health care providers to create

"accountable care organizations" (ACOs), which are designed to coordinate patient care. Instead of separate fees for each procedure, ACOs will receive lump sum payments to care for

patients. The idea is that hospitals and other providers will work harder to provide good care, control costs and keep patients healthy. But ACOs and other measures in the law could

encourage consolidations rather than spur health care competition, some experts say. Hudson of Wilson Hospital says changes in Washington as well as the regional economy were a key reason he

began looking for a partner for his facility. He cites the health care law's lower Medicare rates for hospitals, as well as the expenses involved in adopting new quality controls and

developing electronic record-keeping. WHAT CAN PATIENTS EXPECT? A system of hospitals has greater bargaining power with insurance companies than a single hospital and can therefore demand

higher prices for its services. Robinson of Berkeley examined prices for six major cardiac and orthopedic surgery procedures in hospitals in eight states. His study, published in 2011, found

that private insurers paid 13 to 25 percent more for procedures in areas where there was less competition. In the end, patients wind up paying these increased costs of consolidation —

through higher insurance premiums, copayments, deductibles and hospital bills. And patient care may or may not improve. "There's no clear indication that mergers produce

better-quality care," says Thomas L. Greaney, codirector of the Center for Health Law Studies at Saint Louis University. Of course, hospital systems vary, and Cleveland Clinic's

Cosgrove contends big, busy, experienced medical centers that perform a number of procedures can offer better results and a wider range of services. Over the past 12 years the Cleveland

Clinic has grown to include another three-hospital system and a two-hospital system, as well as several independent community hospitals. "We spent millions enhancing these facilities

and investing them with our mission, vision and values," he wrote recently. The system spans three states and two foreign countries.