hospital transaction prices and managed care discounting for selected medical technologies it is generally assumed that managed care has been successful at capturing discounts from medical providers but the implications have been a matter of debate critics argue that managed care organizations attain savings by reducing intensity of services while others have argued that savings are real and are a consequence of discounts per unit of care rather than reduced intensity because medical services tend to be bundled together into episodes of care separating out prices and quantities can be difficult given available data past studies focused on an average price for the aggregate hospital calculated from total revenue divided by the number of inpatient days or cases e g glenn a melnick et al 1992 emmett b keeler and melnick 1999 david dranove and richard ludwick 1999 caution that these methods provide approximations of actual prices and are subject to measurement error due to unobservable differences in service mix examining treatment episode for acute myocardial infarctions heart attacks david cutler et al 2000 infer that discounts attained by managedcare plans are only partly due to reductions in intensity here we employ data that enable us to observe transaction prices i e actual payments borne by the payer and received by the hospital for major procedures on an unbundled basis our analysis differs from previous studies in several important dimensions among these is the focus on pricing differences between various insurers and employers rather than differences within a single large insurer as a consequence we derive an empirical specification based on the bargaining framework due to john m brooks et al 1997 rather than their insurerbased model moreover to identify pure unit discounts we focus on the narrowly defined procedure like cutler et al we focus on coronary heart disease a leading cause of death we examine a major procedure used to treat this disease one that is costly and relatively common in bypass surgery more fully coronary arterial bypass graft or cabg healthy segments of artery are surgically inserted around the diseased arteries in 2002 about 344 000 cabg s were performed in the united states with expenditures exceeding 21 billion other economists have focused on these procedures to examine market phenomena such as the hospital s entry decision michael chernew et al 2002 or information diffusion dranove et al 2003 yet the pricing decision was not treated fully

the role of firm size in bilateral bargaining a study of the cable television industry we examine the effect of buyer merger on bilateral negotiations between a supplier and n buyers merger may have bargaining effects in addition to the usual efficiency effects the effect of merger on the buyers bargaining position depends on the curvature of the supplier s gross surplus function merger enhances worsens the buyers bargaining position if the function is concave convex based on a panel of advertising revenue in the cable television industry our estimates indicate that the gross surplus function for suppliers of program services is convex this result suggests that cable operators integrate horizontally to realize efficiency gains rather than to enhance their bargaining position vis a vis program suppliers

mass car ownership in the emerging market giants the typical urban household in china owns a tv a refrigerator a washing machine and a computer but does not yet own a car in this paper we draw on data for a panel of countries and detailed household level surveys for the largest emerging markets to document a remarkably stable relationship between gdp per capita and car ownership highlighting the importance of within country income distribution factors we find that car ownership is low up to per capita incomes of about us 5000 and then takes off very rapidly several emerging markets including india and china the most populous countries in the world are currently at the stage of development when such takeoff is expected to take place we project that the number of cars will increase by 2 3 billion between 2005 and 2050 with an increase by 1 9 billion in emerging market and developing countries we outline a number of possible policy options to deal with the implications for the countries affected and the world as a whole marcos chamon paolo mauro and yohei okawa

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

a dynamic theory of countervailing power in this article i develop a model of an infinitely repeated procurement auction with one buyer and several sellers the buyer can accumulate a backlog of unfilled orders which similar to a boom in demand forces the sellers to collude on a low price to prevent undercutting if the buyer s cost of shifiing its consumption over time is low enough then the extent of collusion is bounded away from the joint profit maximizing level even for discount factors approaching one the model is extended to allow for multiple buyers large buyers are shown to obtain lower prices from the sellers buyer mergers increase pro t for all buyers not just the merging pair at the expense of the sellers in contrast buyer growth through addition harms buyers that do not grow and benefits sellers

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

worker substitutability and patterns of unionisation a strategic three party bargaining model is developed in which one distinguished party the firm has to reac h agreements with the other two each of which is a group of workers in the prebargaining stage the two worker groups decide whether to organize jointly or separately the main observation relates the equi librium pattern of unionization to the substitutability in production between the two groups the outcome is joint or separate unions acco rding to whether the two groups are substitute or complementary facto rs of production the analysis also considers possibilities for firm s strategic intervention in the unionization process copyright 1988 by royal economic society

the world economy analysis and prospects the rate of growth for the us has now slipped into the 2 3 range the official figure for 1985 fourth quarter is 2 4 from 6 6 in 1984 growth in the volume of imports has also fallen sharply from almost 23 in 1984 to less than 2 in 1985 although this has been insufficient to prevent further increases in the current account deficit latest trade figures show a record visible trade deficit of 17 4 bn for december 1985

health care costs on the rise again since 1999 health care costs have been growing faster than national income this rapid growth has occurred as the ability of private and public purchasers to reduce service utilization and bargain for lower prices has fallen insurers have recouped lost profits through higher premiums and new technologies have driven up costs throughout the sector private insurance market responses to these rising costs may lead to reductions in the number of people with insurance and to increased fragmentation of the insurance market over time technological change in medicine both increases costs and improves the quality of care the challenge for public policy is to maintain insurance and some degree of equity in the face of these rising costs

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

managed care s price bargaining with hospitals research has shown that managed care mc slowed the rate of growth in health care spending in the 1990s primarily via lower unit prices paid however the mechanism of mc s price bargaining has not been well studied this article uses a unique panel dataset with actual hospital prices in massachusetts between 1994 and 2000 to examine the sources of mc s bargaining power i find two significant determinants of price discounts first plans with large memberships are able to extract volume discounts across hospitals second health plans that are more successful at channeling patients can extract greater discounts patient channeling can add to the volume discount that plans negotiate

bilateral monopolies and incentives for merger the paper presents a model of duopoly in which firms acquire inputs through bilateral monopoly relations with suppliers it combines a bargaining model with a duopoly model to examine how input pri

oil and international energy this article focuses on issues surrounding international oil markets within the wider context of international energy the global economy and conflicting agendas such as energy security and climate change it is suggested that important aspects of the current situation appear unsustainable increasing uncertainty and raising methodological difficulties for any assessment of likely future developments it is argued that the dynamics of oil prices during the 2002 9 cycle reflected great uncertainty about future fundamentals as well as the absence of previously anticipated stabilizing feedbacks from supply from demand or from policy it is suggested that damaging oil price swings could be moderated by better policy though probably not by financial regulation in the longer term the uncertainties remain very great especially since the tensions between a realist view of likely energy market developments and the imperatives of the climate change agenda remain unresolved a wide range of policies in producer and consumer countries are likely to affect not only oil prices but also the contentious issue of the distribution of rents within the industry copyright 2011 oxford university press

the effect of network arrangements on hospital pricing behavior the department of justice doj and the federal trade commission ftc have taken a recent interest in collaborations among hospitals that do not entail common ownership despite the lack of scientific evidence regarding effects of these hospital networks on market competition this paper explores the relationship between hospital networks and pricing behavior in california during a period of dynamic increase in hospital network activity there using herfindahl hirschman indexes hhi market definitions based on patient origin and accounting for network relationships we find a positive network effect on hospital pricing however this result appears to be generated primarily by system owned hospitals that form networks to provide particular services jointly

world oil demand s shift toward faster growing and less price responsive products and regions abstract using data for 1971 2008 we estimate the effects of changes in price and income on world oil demand disaggregated by product transport oil fuel oil residual and heating oil and other oil for six groups of countries most of the demand reductions since 1973 74 were due to fuel switching away from fuel oil especially in the oecd in addition the collapse of the former soviet union fsu reduced their oil consumption substantially demand for transport and other oil was much less price responsive and has grown almost as rapidly as income especially outside the oecd and fsu world oil demand has shifted toward products and regions that are faster growing and less price responsive in contrast to projections to 2030 of declining per capita demand for the world as a whole by the u s department of energy doe international energy agency iea and opec we project modest growth our projections for total world demand in 2030 are at least 20 higher than projections by those three institutions using similar assumptions about income growth and oil prices because we project rest of world growth that is consistent with historical patterns in contrast to the dramatic slowdowns which they project

bootstrapping in small firms an empirical analysis of change over time abstract while bootstrapping is widely utilized as a strategic practice of small firms and has been regarded in the entrepreneurship literature as an important topic of study little has been done to link bootstrapping to organizational theory this paper presents hypotheses and an empirical study regarding bootstrapping and organizational development for small firms the results of the study indicate that different types of bootstrapping are utilized at different periods in the life of a small firm and that the methods utilized coincide to some extent with organizational theory predictions

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

vehicle ownership to 2015 implications for energy use and emissions abstract this paper forecasts the growth in car ownership to the year 2015 for organization for economic co operation and development oecd countries and a number of asian economies and estimates the implications of this growth on energy demand and emissions the vehicle forecasts are based on models derived from distribution functions which relate the car stock to income and population the models are dynamically specified so that short and long run income elasticities are estimated for the individual countries the question of vehicle saturation both in terms of ownership levels and time is analysed as are the similarities and differences in the demand relationships among the various countries the forecasts of car ownership are combined with income and population projections and assumptions on possible trends in vehicle use fuel efficiency and fuel prices to produce a range of estimates of fuel consumption co 2 emissions the paper concludes with a discussion of the implications of the results for energy environmental and transport policy

the value of consumer choice and the decline in hmo enrollments i introduction and overview health insurance contracts may restrict consumers choice of medical provider in order to minimize moral hazard for example consumers who are insured for their marginal healthcare expenses have no incentive to enforce price discipline on their own in this case insurers may impose this discipline by restricting consumers choice of medical provider to those who offer competitive prices 1 this practice known as selective contracting sc may have other benefits as well including channeling consumers to efficient providers and achieving other efficiencies associated with partial vertical integration sc has been utilized by insurers both in the united states and abroad 2 however it is not a universal feature of health insurance contracts in part this is because reducing the choice set of medical providers imposes costs on consumers to the extent that consumers assign option value to choice capps dranove and satterthwaite 2003 for example sc was widely employed in the united states by health maintenance organizations hmos and other insurers in the 1990s and appears to have been an important cost control mechanism cutler mcclellan and newhouse 2000 robinson and phibbs 1989 however most private u s health insurers moderated their use of sc during the past decade at the same time that healthcare costs accelerated anecdotally a consumer and regulatory backlash against provider choice restrictions forced insurers to expand choice and largely abandon the practice blendon et al 1998 vita 2001 simultaneously hmo enrollments declined the purpose of this article is to explore the economic tradeoffs of sc with a particular focus on directly measuring the value that consumers assign to choice in medical markets i am interested in assessing whether the magnitude of any utility loss from choice restrictions can be offset by volume based price discounts that insurers may receive from hospitals my results bear on the larger question of whether an economic linkage can be drawn between consumers demand for choice and their apparent rejection of what is called tightly managed care they also have implications for many healthcare reform proposals that necessarily imply restrictions on the consumers choice sets i analyze health plan s sc of hospitals in the state of florida between 1999 and 2003 hospital sc restricts consumer choice in multiple ways including their choice of hospital in addition hospital choice restrictions imply restrictions over the use of specific physicians 3 i start by constructing hospital networks for each of a set of plan choices and then estimate a discrete choice model of health insurance demand conditional on each plan s restricted network for these purposes i use the capps dranove and satterthwaite 2003 measure of sc disutility that focuses on the option value of choice i employ several different discrete choice estimators to estimate the model including models with plan metropolitan statistical area msa fixed effects designed to control for unobserved plan attributes this provides me with estimates of disutility resulting from choice restrictions subsequently i project the estimated plan effects onto an instrumented value of plan price in order to estimate the price elasticity and also convert my disutility estimates into dollars my results show that consumers associated restrictive hospital networks with plan disutility during each of the years of the study period with choice elasticities that range from 0 10 to 0 32 in pooled estimates greater effects are obtained in 2003 using models where i allow the estimates to vary by year using my instrumental variables methodology to recover unbiased price coefficients i show that consumers associated a one standard deviation reduction in the size of a plan s hospital network with a reduction in plan value of between 62 and 118

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

enrollee mix treatment intensity and cost in competing indemnity and hmo plans abstract why do indemnity insurance plans cost substantially more per capita 77 more in our study than hmos we answer this question using data from a large organization s insurance pool covering 215 000 lives we decompose cost differences for eight major medical conditions into four sources demographics incidence within demographic groups treatment intensity and prices per service greater incidence of disease in the indemnity plan both from demographics themselves and within demographic groups and higher prices each explain nearly 50 of the difference contrary to conventional wisdom indemnity plans do not have greater treatment intensity

why do larger buyers pay lower prices intense supplier competition abstract the paper provides a theoretical explanation of the common claim that larger buyers pay lower prices in the model suppliers compete more aggressively for the business of larger buyers much as they do in boom periods of rotemberg and saloner

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