What is payer vertical integration?
Payer vertical integration is the combination, under one owner, of steps that used to belong to different companies: the health plan that sells coverage also owns the hospitals, emergency rooms, clinics and labs where members are treated. It also happens the other way around, when a hospital or hospital group creates its own health plan.
In Brazil, health plans are called operadoras and are regulated by the ANS (Agência Nacional de Saúde Suplementar, the national private health insurance regulator). For the operadora, the logic is to control medical costs. Instead of paying an independent provider's bill, item by item or as a case rate, it funds its own facilities and allocates the cost internally. The market context is in the pillar guide Brazilian private healthcare.
For an independent hospital, one not owned by any health plan, vertical integration means part of a payer's patients now have a preferred destination elsewhere. The effect shows up in volume, in price and in each side's strength at the negotiating table.
The numbers on vertical integration in 2025
The best public, recurring measure of vertical integration is the share of healthcare expenses that medical-hospital health plans record as cost allocation of own resources. The figure comes from ANS open data, processed by Arquitetos da Saúde and published by Anahp (Associação Nacional de Hospitais Privados, Brazil's association of leading private hospitals) in its quarterly Balanço Observatório Anahp [1].
| Payment method (% of healthcare expenses) | 2019 | 2024 | 2025 |
|---|---|---|---|
| Fee-for-service (item by item) | 83.7% | 58.5% | 58.6% |
| Cost allocation of own resources (own network) | 6.9% | 13.7% | 13.0% |
| Case rate (pacote) | 3.8% | 12.0% | 13.1% |
| Provided through indirect network | 0.0% | 9.2% | 8.5% |
Source: Anahp, Balanço Observatório Anahp (Anahp Observatory Report), 9th edition, March 2026, Tables 8 to 10, ANS open data processed by Arquitetos da Saúde [1].
Three readings stand out. First, the own-network share roughly doubled between 2019 and 2024 and held in 2025; Anahp attributes the rise to the growth of vertical integration in recent years [1]. Second, fee-for-service, the basis of traditional hospital billing, fell from 83.7% to 58.6% over the same period [1]. Third, own network and case rates together now exceed a quarter of healthcare expenses [1].
Two caveats. The indicator measures money, not number of hospitals: it shows how much healthcare spending is booked as the cost of owned facilities. And the report does not define “own resources” or “indirect network” [1]; the numbers show a trend and do not support comparing individual health plans. No current public primary source with the number of hospitals owned by health plans was found.
Who integrates the most: differences by plan type
Vertical integration is not market-wide. It is concentrated in three plan types and nearly absent in two [1]:
See the numbers as a table
| Plan type | 2019 | 2024 | 2025 |
|---|---|---|---|
| Philanthropic | 33.0% | 40.9% | 40.8% |
| Medical cooperative | 12.1% | 20.6% | 22.9% |
| Group medicine | 7.8% | 21.3% | 17.1% |
| Self-managed | 0.7% | 1.3% | 1.3% |
| Insurer | 0.0% | 0.0% | 0.0% |
| Plan type | Own network 2019 | 2024 | 2025 | Case rate 2025 | Loss ratio 2025 (excluding technical provisions) |
|---|---|---|---|---|---|
| Philanthropic (filantropia) | 33.0% | 40.9% | 40.8% | 0.4% | 80.70% |
| Medical cooperative | 12.1% | 20.6% | 22.9% | 2.5% | 80.31% |
| Group medicine (medicina de grupo) | 7.8% | 21.3% | 17.1% | 18.0% | 75.09% |
| Self-managed (autogestão) | 0.7% | 1.3% | 1.3% | 5.3% | 91.72% |
| Insurer (seguradora) | 0.0% | 0.0% | 0.0% | 25.3% | 78.32% |
Source: Anahp, Balanço Observatório Anahp, 9th edition, March 2026, Tables 3, 9 and 10 [1]. Percentages of each plan type's healthcare expenses. The loss ratio (sinistralidade) in this table excludes technical provisions and is not comparable with the overall market series.
Philanthropic plans are nonprofit entities that run health plans. At medical cooperatives, the own network rose in both readings after 2019 (12.1%, 20.6% and 22.9%). At group medicine companies, the jump was the largest through 2024, with a pullback in 2025 [1].
Insurers follow a different path. In the data, they record no own-network spending (0.0% in all three years); the tool that shows up most is the case rate, which reached 25.3% of their spending in 2025 [1]. For the hospital, the pressure on revenue takes a different form depending on plan type: with group medicine and cooperatives, the risk is losing volume to the own network; with insurers, it is accepting a poorly priced bundled rate. Models are compared in the guide Hospital payment models, and the loss ratio is explained in Health plan loss ratio.
Why does vertical integration shift negotiating power?
Vertical integration shifts negotiating power because it gives the health plan an alternative to the contracted hospital. A payer that can send patients elsewhere negotiates price, payment terms and denial (claim denial) from a different position.
The effect tends to be larger when the market is concentrated. In 2025, the ten largest health plans held 43% of members and about 71% of the sector's net income [1]. On the other side, hospitals depend on health plans: at Anahp members, they accounted for 76.47% of gross revenue in 2025 and 80.21% in the first quarter of 2026 [1][3]. A hospital with a vertically integrated plan among its largest payers has revenue exposed to a decision it does not control.
In practice, the loss of leverage can appear in three ways:
- Volume. Elective admissions and higher-margin procedures may be steered to the own network, and the hospital may be left with what the own network cannot absorb, such as emergencies, complex cases and demand peaks.
- Price and annual increase. With an in-house alternative, the payer has less urgency to close the annual rate increase. Law 9,656/1998 requires the increase to be negotiated in the first 90 days of the year and, without agreement, applies the ANS index where applicable [2]. The calendar is in Payer rate negotiation.
- Payment terms. The temptation to stretch payment terms or tighten claim audits grows when the hospital has little room to say no. Protective clauses are in Hospital-payer contract.
Vertical integration is also an antitrust matter. Law 12,529/2011 (Lei 12.529/2011, Brazilian Competition Law) presumes a dominant position when a company or group controls 20% or more of the relevant market (a threshold CADE may change by sector), and lists, among conduct that may be an infringement, discriminating between buyers through differentiated prices and refusing to sell or provide services on normal payment terms [4]. Review of mergers between health plans and hospitals falls to CADE (Conselho Administrativo de Defesa Econômica, Brazil's antitrust authority). This guide does not describe what a hospital “can” obtain from this: any action depends on legal analysis of the specific case.
What the law guarantees to a contracted hospital
The law protects continuity of care for members, not the hospital's place in the network. It is important to keep the two apart.
Article 17 of Law 9,656/1998 (Lei 9.656/1998, the Health Plans Law) says that including a provider in the network commits the health plan to keep it for the term of its member contracts. A hospital may be replaced only by an equivalent one, with notice to members and to the ANS 30 days in advance [2]. If a patient is admitted, the replaced hospital keeps the patient until discharge, paid by the health plan [2]. Reducing the hospital network without a replacement requires prior, express ANS approval, with a justification of the impact on the covered population [2].
ANS Normative Resolution 585/2023 (RN 585/2023) regulates this article. It requires the replacement to be equivalent and in the same municipality; if none exists, in a neighboring municipality or the same health region [5]. For the independent hospital, the practical consequence is that a vertically integrated plan's exit tends to be gradual and documented, which leaves time to react. The steps are in the guide Provider network termination.
The written contract is the other protection. Since Law 13,003/2014, article 17-A of Law 9,656/1998 requires a contract with billing and payment terms, rate-increase criteria, duration and termination rules [2]. RN 503/2022 details these clauses [6]; the article-by-article explanation is in RN 503: what the payer contract must say.
Strategies for independent hospitals
There is no single recipe, but the responses seen in the sector fall into five fronts. The table sums up what each one requires from the revenue cycle.
| Strategy | What it is | What it requires from the revenue cycle | Main risk |
|---|---|---|---|
| Diversify the payer mix | Reduce the weight of the largest payer by adding insurers, self-managed plans and regional health plans | Revenue and margin by payer and plan type, month by month | Signing contracts with worse payment terms or denial rates |
| Specialize in what the own network does not do | High complexity, oncology, cardiology, maternity, referral emergency care | Cost per service line to know where the margin is | Concentrating revenue in a few service lines |
| Offer case rates and alternative models | Case rates with clear scope and exclusions, or performance-based models | Real cost per procedure and history of complications | A poorly priced case rate losing money with no denials at all |
| Serve the own network as overflow | Contract to absorb the integrated plan's overflow, peaks and complex cases | Payment terms and denials tracked separately for that contract | Unstable volume and little pricing power |
| Strengthen the contract | Well-drafted clauses on payment terms, increases, audit and termination | Proof for each denial, protocol for each submission, record of each delay | Good clauses on paper that are never enforced |
There is also the reverse path, in which the hospital or group creates its own health plan. It requires an ANS operating license and compliance with the solvency and coverage rules of Law 9,656/1998 [2], and turns the hospital into a health plan, with a different kind of risk.
On every front, the starting point is the same: knowing how much each health plan weighs in revenue, how much it actually pays and how fast. Without that picture, negotiation becomes perception against data.
What we see in operations
At Accrua, we follow each health plan through billing metrics, claim by claim: volume, case mix, average claim value, initial denials, accepted denials and payment time. When a health plan changes how it uses its network, the effect can show up in these numbers before any formal notice: fewer elective admissions, more emergency or high-complexity cases, different payment timing.
In the diagnostic, we break the hospital's history down by health plan and separate those with their own network from those without one. This reading shows the hospital's real dependence, the health plan that weighs most on cash and the profile of the claims each one sends.
For an independent hospital, this reading serves both negotiation and cash. Receita Garantida reads risk by health plan, plan type and claim type, puts the value of eligible production into the hospital's cash on the timeline it needs and takes on the risk of eligible denials. That separates the commercial decision about each health plan from the month's cash needs.
Where to start
- Measure dependence: each health plan's and each plan type's share of gross revenue over the last 12 months.
- Identify who is integrating among your five largest payers and in which regions the own network competes with your hospital.
- Track performance by payer: initial denial rate, accepted denials, days to payment and monthly volume, to spot change early.
- Review the contracts of your largest payers: payment terms, rate increase, termination and network substitution.
- Calculate cost per service line before proposing case rates or negotiating an overflow role for an own network.