Rhode Island Affordability Standards and Hospital-Affiliated Clinicians’ Professional Fees

Importance: In response to growing concerns about increasing hospital prices, Rhode Island placed caps on facility fee growth in 2010 through its Affordability Standards. Research found that the price growth caps successfully reduced hospital facility fees relative to other states. However, hospitals' response to revenue loss from the Affordability Standards-including seeking to acquire more clinicians and increasing nonregulated professional fees for affiliated clinicians-is unknown. Objective: To compare changes in vertical integration and changes in professional fees for evaluation and management services for clinicians affiliated with Rhode Island hospitals with such changes for clinicians affiliated with hospitals in other New England states. Design, Setting, and Participants: This cross-sectional study used January 1, 2013, through December 31, 2019, commercial claims data from the Health Care Cost Institute data contributors and data on vertically integrated clinicians. The analytic sample included 5 364 983 evaluation and management services performed by 10 352 hospital-affiliated clinicians in Rhode Island and other New England states. Analyses were performed from April 2024 through December 2025. Main Outcomes and Measures: Study outcomes included the share of vertically integrated clinicians and professional fees per evaluation and management encounter. Results: The study included 2 292 504 commercial enrollees (Rhode Island vs other New England states: female, 64.8% vs 59.6%; and age ≥65 years, 6.8% vs 6.4%). In 2013, vertically integrated clinicians accounted for a smaller share in Rhode Island vs other New England states (32.0% vs 46.4%), as did mean (SD) professional fees per evaluation and management encounter ($105.8 [$37.9] vs $141.7 [$61.8]). Vertical integration increased more slowly in Rhode Island compared with neighboring states (-0.4 percentage points [95% CI, -0.7 to -0.1 percentage points]) and the annual change in professional fees for hospital-affiliated clinicians in Rhode Island was $1.55 (95% CI, -$2.02 to -$1.08) lower per service than for those in other New England states. Conclusions and Relevance: This cross-sectional study of vertical integration and professional fees in Rhode Island compared with surrounding New England states found that Rhode Island hospitals did not circumvent the Affordability Standards through increased vertical integration activity or professional fees among integrated clinicians. This research suggests that hospital facility fee regulations may limit hospital bargaining leverage and market power along with price increases more broadly.