urgent basis. 99 Caregiver stress is an established predictor of nursing home placement and an independent risk factor for the caregiver’s morbidity and mortality. 100 However, health industry consolidation by itself is unlikely to exacerbate or mitigate the policy challenges surrounding caregiver burden, unless consolidation results in reduced or total unavailability of formal, professional LTSS providers in a particular geographic location. To the extent that self-pay consumers need or choose to use institutional or agency LTSS providers in whole or part for companion care or specific services requiring specialized training and licensure, the effects of current consolidation in the healthcare industry may be positive or negative. On the positive side, greater efficiency (if indeed facilitated by consolidation of providers) could result in better coordination and continuity of care for self- pay consumers who employ multiple institutional or agency LTSS providers; that development should then translate into enhanced quality of care. On the negative side, if consolidation means a smaller number of institutional and agency LTSS providers are vying for each consumer’s business, that may mean less consumer choice and hence less incentive on the providers’ part to compete on the basis of price or quality. Self-pay consumers, whose interests are not represented by a government agency or private insurer, are left to their own bargaining power and acumen in negotiating deals with providers for their care, potentially placing them at a disadvantage. By the same token, because LTSS providers may perceive self-pay consumers as affluent, and therefore desirable, they may be more flexible in negotiating the terms of a relationship with such consumers than they would be in negotiating service or compensation details with insured consumers or their third-party payers. The surmises presented here are, to some degree, susceptible to either empirical verification or disproof. A health services research agenda concerned with LTSS could investigate the impact, if any, of health industry consolidation on the availability of unaffiliated direct-care workers and institutional and agency services for self-pay consumers, as well as changes in the price and quality of LTSS available to and received by those consumers.
99. Ranak Trivedi et al., Characteristics and Well-Being of Informal Caregivers: Results from a Nationally-Representative US Survey, 10 CHRONIC ILLNESS 167, 171-73 (2014); Susan Reinhard et al., Valuing the Invaluable: 2015 Update, Undeniable Progress, But Big Gaps Remain, AARP PUB. POL’Y INST. (July 2015), http://www.aarp.org/content/dam/aarp/ ppi/2015/valuing-the-invaluable-2015-update-new.pdf. But see David L. Roth, Lisa Fredman, & William E. Haley, Informal Caregiving and Its Impact on Health: A Reappraisal from Population-Based Studies, 55 GERONTOLOGIST 309 (2015) (discussing potential benefits realized by family caregivers). 100. Thomas & Appelbaum, supra note 61, at 59.