hospital choices hospital prices and financial incentives to physicians we estimate an insurer speci c preference function which rationalizes hospital referrals for privately insured births in california the function is additively separable in a hospital price paid by the insurer the distance traveled and plan and severity speci c hospital xed eects capturing hospital quality we use an inequality estimator that allows for errors in price and detailed hospital severity interactions and obtain markedly dierent results than those from a logit the estimates indicate that insurers with more capitated physicians are more responsive to price capitated plans send patients further to utilize similar quality lower priced hospitals but the cost quality trade odoes not vary with capitation rates the patient protection and aordable care act of 2010 includes provisions to establish ac countable care organizations acos in the medicare program these are groups of health care providers that oer services to a large number of patients and are eligible to share in any cost savings they achieve for the medicare program 1 private sector acos are forming in parallel to this initiative often with very similar structures and payment arrangements the proportion of savings acos keep is linked to their performance on quality standards the goal of the initiative is to reduce health care costs in both medicare and private insurance and to improve coordination of care the tying of cost savings to quality standards is designed to mitigate the concern that an increase in incentives to control costs might lead to a decrease in the quality of care the health policy literature has noted that similar cost control incentives are currently utilized by some health maintenance organizations hmos in california and elsewhere 2 in this paper we investigate the impact of these incentives on the cost and quality of care provided to patients focusing in particular on the choice of hospital for privately insured patients giving birth we use

physician payment reform and hospital referrals commercial health insurers in california use provider capitation payments to different extents these are similar to arrangements introduced by the recent health reforms to give physicians incentives to control costs in a previous paper we showed that patients whose insurers used capitation incentives traveled further to access lower priced similar quality hospitals than other same severity patients this paper predicts the implied effects of a move to widespread capitation we show that if the introduction of capitation prompted low capitation insurers to act like high capitation insurers this would generate a 4 5 percent cost saving with some reduction in patient convenience but no reduction in quality

hospital systems and bargaining power evidence from out of market acquisitions competition analyses generally restrict their attention to how mergers alter concentration in the relevant consumer market studying hospital competition by focusing on the local patient market may be misleading however as multi market hospital systems often play an important role in the price negotiations of their members with managed care organizations we focus on out of market hospital mergers to investigate the cross market effects of system membership on member hospital reimbursement rates based on acquisitions occurring across the united states during 2000 2008 we find that hospitals exhibit significant increases of around 14 in their net reimbursement rates after becoming affiliated with an out of market system compared to independent stand alone hospitals we find no evidence that the price effect results from changes in patient case mix the cost of providing care generally or hospital quality the findings reveal that systems can impact the market power of hospitals in ways that have not been considered in recent antitrust analysis

insurer hospital bargaining negotiated discounts in post deregulation connecticut this paper uses unique data from the state of connecticut to examine discounting patterns in the state s hospital industry for the years following deregulation 1995 1998 the data provide a rare opportunity to study payer level differences in negotiated discounts for hospital services in addition to presenting descriptive evidence on how discounts vary across payers payer types and hospital types this study uses matched revenue data to analyze the economic determinants of discount magnitudes payer size appears to affect bargaining power but the economic significance of the effect is small the data exhibit patterns consistent with a bargaining explanation in which discount magnitudes depend critically on payers abilities to channel patients to hospitals with which favorable discounts have been negotiated

effects of deregulation and consolidation of the broadcast television industry this paper exploits deregulation in the 1990s to estimate viewership and revenue effects of consolidation in broadcast television then finds cost effects that explain the ownership structure given viewer ship and revenue effects results suggest that consolidation greatly increased profitability in an industry with otherwise declining profitability groups with broader national coverage attract more advertising per station joint ownership of two stations within a market and network ownership both allow for significant cost savings there is some evidence that within market consolidation allows stations to achieve local market power however both within market and across market consolidation appear to have boosted viewership on net jel g32 l13 l25 l51 l82 l88 deregulation of the telecommunications industry in the 1990s led to substantial consolidation in the local broadcast television industry which provoked considerable controversy critics of the deregulation argue that cost cutting led to lower quality programming broadcast groups counter that consolidation is necessary to make high quality broadcast programming viable in the face of increasing competition from other content providers that are not subject to the same strict ownership regulations as broadcasters to what extent did the consolidation that took place in the decade following deregulation actually improve the profitability of broadcast stations is there any evidence that consolidation had negative effects such as reduced programming quality or local market power a priori the answers are not obvious due to remaining regulations the vast majority of consolidation involved stations in different local markets which are not in direct competition with one another and are often hundreds of miles apart how does nexstar broadcasting s ownership of an nbc affiliated station in

competition among hospitals we examine competition in the hospital industry in particular the effect of ownership type for profit not for profit government we estimate a structural model of demand and pricing in the hospital industry in california then use the estimates to simulate the effect of a merger california hospitals in 1995 face an average price elasticity of demand of 4 85 not for profit hospitals face less elastic demand and act as if they have lower marginal costs their prices are lower than those of for profits but markups are higher we simulate the effects of the 1997 merger of two hospital chains in san luis obispo county where the merger creates a near monopoly prices rise by up to 53 and the predicted price increase would not be substantially smaller were the chains not for profit

floating exchange rates in peru 1950 1954 abstract three potentially complementary models are tested in an effort to capture the fundamentals that underlaid the market s determination of peru s floating exchange rate through the period 1950 1954 the first is an expectational purchasing power parity ppp model which maintains that asset market forces were driving the exchange rate to its perceived ppp level the second is a flexible price monetary model and the thrid is a model along the lines described by tsiang 1957 which emphasizes world prices for peruvian exports as a fundamental determinant i find that the expectational ppp model not only dominates the others but also fits quite well

price and concentration in hospital markets the switch from patient driven to payer driven competition perhaps the most widely accepted paradigm of industrial organization i o is that competition lowers prices or alternatively that price cost margins are lower in less concentrated markets 1 the applicability of this paradigm for hospital markets has been questioned for example in united states vs carilion health system and roanoke valley hospital the district and appellate courts accepted evidence that hospital prices are lower in more concentrated markets and thereby approved a merger between the two largest hospitals in a three hospital market 2 the view that competition has a weak or perverse effect on hospital prices is shared by a number of researchers 3 is a common theme in newspaper stories

why do previous choices matter for hospital demand decomposing switching costs from unobserved preferences abstract using data on women s choice of hospital for childbirth in florida we find that women return to the same hospital approximately 70 of the time we separate explanations of switching cost

the industrial organization of health care markets the u s health care sector is large and growing health care spending in 2011 amounted to 2 7 trillion and 18 percent of gdp approximately half of health care output is allocated via markets in this paper we analyze the industrial organization literature on health care markets focusing on the impact of competition on price quality and treatment decisions for health care providers and health insurers we conclude with a discussion of research opportunities for industrial organization economists including opportunities created by the u s patient protection and affordable care act

hospital ownership and public medical spending the hospital market is served by firms that are private for profit private not for profit and government owned and operated i use a plausibly exogenous change in hospital financing that was intended to improve medical care for the poor to test three theories of organizational behavior i find that the critical difference between the three types of hospitals is caused by the soft budget constraint of government owned institutions the decision makers in private not for profit hospitals are just as responsive to financial incentives and are no more altruistic than their counterparts in profit maximizing facilities my final set of results suggests that the significant increase in public medical spending examined in this paper has not improved health outcomes for the indigent i introduction the hospital market is served by firms that are private for profit private not for profit and publicly owned and operated in this paper i examine how a hospital s type of ownership influences its response to profitable opportunities that are created by changes in government policy the policy change that i exploit was designed to improve the quality of medical care for lowincome individuals by significantly increasing hospitals financial incentives to treat them this program also substantially increased the revenues of those hospitals that had been serving a disproportionate share of the indigent i use this plausibly exogenous change in government policy to test three different theories of organizational behavior and then to assess the impact of hospital behavioral responses on health outcomes the response of organizations to changes in government policy will have an important impact on the consequences of these policies this is likely to be especially true in the medical sector in which the federal state and local governments contract directly

mergers when prices are negotiated evidence from the hospital industry in recent years many hospitals have merged in part to gain bargaining leverage with managed care organizations mcos we investigate the price impact of hospital mergers by formulating and estimating an equilibrium bargaining model between hospital systems and managed care health insurers over prices for inpatient services we estimate the parameters of the model using claims and discharge data from northern virginia in 2006 inova health system proposed to acquire prince william hospital we nd that this merger would have raised prices signicantly and that the remedy of separate bargaining imposed by the ftc in a separate hospital case would have resulted in a larger price increase

the changing effects of competition on non profit and for profit hospital pricing behavior abstract has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors this paper uses time series cross sectional methods on california hospital discharge data from 1986 1994 to show the association of hospital prices with measures of market concentration changed steadily over this period with prices now higher in less competitive areas even for non profit hospitals regression results are used to simulate the price impact of hypothetical hospital mergers

a semiparametric discrete choice model an application to hospital mergers we propose a computationally simple semiparametric discrete choice estimator to model rich consumer heterogeneity we assume groups of observably similar consumers have similar preferences but allow preferences to vary freely across these groups model flexibility is easily adjusted by setting a single tuning parameter we suggest a cross validation method to do so we analyze the model s properties in the context of hospital mergers both analytically and via a monte carlo analysis the model performs well for policy relevant substitution and welfare measures even if misspecified when the tuning parameter is set within the neighborhood of the value chosen by cross validation jel c14 d12 i11 l41

the welfare effects of restricted hospital choice in the us medical care market summary managed care health insurers in the usa restrict their enrollees choice of hospitals to within specific networks this paper considers the implications of these restrictions a three step econometric model is used to predict consumer preferences over health plans conditional on the hospitals they offer the results indicate that consumers place a positive and significant weight on their expected utility from the hospital network when choosing plans a welfare analysis assuming fixed prices implies that restricting consumers choice of hospitals leads to a loss to society of approximately 1 billion per year across the 43 us markets considered this figure may be outweighed by the price reductions generated by the restriction copyright 2006 john wiley sons ltd

assessing competition in hospital care markets the importance of accounting for quality differentiation quality differentiation is especially important in the hospital industry where the choices of medicare patients are unaffected by prices unlike previous studies that use geographic market concentration to estimate hospital competitiveness this article emphasizes the importance of quality differentiation in this spatially differentiated market i estimate a random coefficients discrete choice model that predicts patient flow to different hospitals and find that demand responses to both distance and quality are substantial the estimates suggest that patients do not substitute toward alternative hospitals in proportion to current market shares implying that geographic market concentration is an inappropriate measure of hospital competitiveness

hospital insurer bargaining an empirical investigation of appendectomy pricing employers increased sensitivity to health care costs has forced insurers to seek ways to lower costs through effective bargaining with providers what factors determine the prices negotiated between hospitals and insurers the hospital insurer interaction is captured in the context of a bargaining model in which the gains from bargaining are explicitly defined appendectomy was chosen because it is a well defined procedure with little clinical variation our results show that certain hospital institutional arrangements e g hospital affiliations hmo penetration and greater hospital concentration improve hospitals bargaining position furthermore hospitals bargaining effectiveness has diminished over time and varies across states

is hospital competition socially wasteful we study the consequences of hospital competition for medicare beneficiaries heart attack care from 1985 to 1994 we examine how relatively exogenous determinants of hospital choice such as travel distances influence the competitiveness of hospital markets and how hospital competition interacts with the influence of managed care organizations to affect the key determinants of social welfare expenditures on treatment and patient health outcomes in the 1980s the welfare effects of competition were ambiguous but in the 1990s competition unambiguously improves social welfare increasing hmo enrollment over the sample period partially explains the dramatic change in the impact of hospital competition

hospital competition in hmo networks abstract we develop a framework for analyzing bargaining relationships between hospitals and hmos under selective contracting using a unique dataset on hospitals in the los angeles area from 1990 to 1993 we estimate the determinants of actual negotiated prices paid to hospitals by two major hmos we find that a hospital s bargaining power and thus its price decrease when the hmo can readily turn to alternative networks that exclude the hospital we simulate the effect of hypothetical hospital mergers on bargaining power and find that some hospital mergers even in urban areas with many nearby hospitals can lead to significant price increases

insurer provider networks in the medical care market i use data on the hospital networks offered by managed care health insurers to estimate the expected division of profits between insurers and providers i include a simple profit maximization framework and an additional effect hospitals that can secure demand without contracting with all insurers e g those most attractive to consumers and those that are capacity constrained may demand high prices that some insurers refuse to pay hospital mergers may also affect price bargaining i estimate that all three types of hospitals capture higher markups than other providers these results provide information on the hospital investment incentives generated by bargaining

the effects of market structure and bargaining position on hospital prices ppos and hmos have gained widespread acceptance due in part to the belief that excess capacity and competitive market conditions can be leveraged to negotiate lower prices with health care providers we investigated prices obtained in different types of markets by the largest ppo in california our findings indicate that greater hospital competition leads to lower prices furthermore as the importance of a hospital to the ppo in an area increases the price rises substantially our testing of alternative methods for defining hospital geographic markets reveals that the common practice of using counties to define the market leads to an underestimate of the price increasing effects of a merger

market structure and multiple equilibria in airline markets we provide a practical method to estimate the payoff functions of players in complete information static discrete games with respect to the empirical literature on entry games originated by bresnahan and reiss 1990 and berry 1992 the main novelty of our framework is to allow for general forms of heterogeneity across players without making equilibrium selection assumptions we allow the effects that the entry of each individual airline has on the profits of its competitors its competitive effects to differ across airlines the identified features of the model are sets of parameters partial identification such that the choice probabilities predicted by the econometric model are consistent with the empirical choice probabilities estimated from the data we apply this methodology to investigate the empirical importance of firm heterogeneity as a determinant of market structure in the u s airline industry we find evidence of heterogeneity across airlines in their profit functions the competitive effects of large airlines american delta united are different from those of low cost carriers and southwest also the competitive effect of an airline is increasing in its airport presence which is an important measure of observable heterogeneity in the airline industry then we develop a policy experiment to estimate the effect of repealing the wright amendment on competition in markets out of the dallas airports we find that repealing thewright amendment would increase the number of markets served out of dallas love

reforming payments to healthcare providers the key to slowing healthcare cost growth while improving quality the seemingly intractable debate about how to slow the growth of healthhe seemingly intractable debate about how to slow the growth of healthcare costs in the united states and elsewhere has traditionally boiled care costs in the united states and elsewhere has traditionally boiled down to efforts to limit prices and quantities directly in public healthdown to efforts to limit prices and quantities directly in public healthcare programs the focus in the united states is often on tighter price regulation care programs the focus in the united states is often on tighter price regulation for example the balanced budget act of 1997 achieved most of its savings by for example the balanced budget act of 1997 achieved most of its savings by reducing the growth of regulated prices in medicare for physicians hospitals reducing the growth of regulated prices in medicare for physicians hospitals and most other healthcare providers the affordable care act of 2010 also and most other healthcare providers the affordable care act of 2010 also achieved most of its scored budgetary savings which were used as a partial achieved most of its scored budgetary savings which were used as a partial offset for the costs of coverage expansions through reducing medicare price offset for the costs of coverage expansions through reducing medicare price growth elmendorf 2010 a

on the measurement of σ convergence abstract we demonstrate that two popular measures of inequality related to the discussion of convergence lead to different conclusions when used on data from penn world table the reason is that the measures assign different weights to individual countries growth performance

market share and the illusion of power can blue cross force hospitals to discount researchers in health care financing have claimed that large private insurers like blue cross frequently exercise monopsony power to obtain discounts from normal hospital charges they claim that the monopsony power derives from a large blue cross share of a given hospital cost shifting whereby hospitals offset the discount by raising charges to less powerful customers this paper re examines both theoretically and empirically the conditions necessary for a private insurer to extract discounts from a hospital we demonstrate that the theoretical conditions necessary for blue cross to force a discount do not exist in the indiana market using revenue data from 110 indiana hospitals we reject the traditional claim that blue cross pays less than other insurers as a function of market share