Oct. 21, 2009

HSPM 712

Competition (supply side) of health insurance market

• THE most complicated thing that people buy

Insurers compete

• Pre-existing condition exclusions• Retroactive cancellation

How much money do insurance companies make -- Reinhardt

• Health benefit ratio– New euphemism for Medical Loss Ratio– Wellpoint: • $48 million paid out• Premium revenue $57 million• HBR about 84%

– SG&A $9 million 14% of revenue– Profits 4% of revenue

What portion of premiums should insurers pay out -- Reinhardt

• Individual market – high cost to contract with individuals leads to low medical loss ratio

• Would eliminating these costs make up for the extra that low-risk people will be paying, if underwriting is outlawed?

Cost shift from government patients to private patients? -- Reinhardt

• Price discrimination– Most common where fixed cost is big, marginal

cost is small compared with average fixed cost.– Charge each buyer what it’s worth to him or her.

Risk adjustment in Baucus bill

Monopoly theory and antitrust laws

• Monopoly and Competition Theory • "Monopoly" means one seller. It comes from Greek

words meaning one (mono) seller (polein, which is Anglicized to "poly"). The term is used broadly to include industries of several sellers who act as one. The correct term for a "buyers' monopoly," where there is only one buyer, is "monopsony."

• "Oligopoly" means a small number of sellers. The automobile industry is an example of an oligopoly. So is the hospital services industry in most small to medium-sized market areas.

Monopoly theory and antitrust laws

• Monopoly and Competition Theory • Where is the dividing line between oligopoly

and competition? The functional distinction is this: An oligopoly exists if one seller's actions can affect another seller's demand.

Structure, Conduct, and Performance

• Economists analyze a market under three categories: Structure, Conduct, and Performance.

• Structure is the context in which the actors in the market make their decisions.

• Conduct is what decisions the actors make. • Performance is what we get as a result in

terms of efficiency and equity.

Structure

• Concentration: How many sellers are in the market and how big the bigger sellers are relative to the market as a whole.

• Barriers to entry: How hard it is for a new firm to enter the market. Another way to think of this is: Are there potential competitors?

• Product differentiation: Can you tell one firm's product from another's?

Conduct

• Collusive behavior. Do the firms attempt to act as one?

• Competitive behavior. Do the firms attempt to undercut each other?

• Product differentiation. How do the firms try to distinguish their products?

Performance

• Whether costs are minimized• Whether prices are high relative to cost• Quality• Pace of technological progress and innovation.

Structure-Conduct relation

• Structure determines whether conduct matters. • Conduct doesn't matter in a perfectly competitive

market, because any firm that doesn't minimize cost and keep its price low is out of business.

• Conduct matters in monopolized markets. The monopolist may or may not take advantage of its position.

• Conduct is most complex in oligopolized markets. An oligopoly can act like a monopoly, like competition, or like something else that conforms to neither of those models.

Natural monopolies

• Natural monopolies -- if it is most efficient to have one seller serve an entire market. Local utility service may be an example, because it would be costly to have two sets of water pipes, electrical lines, or telephone lines to each house.

Natural oligopolies

• Industries may be natural oligopolies, if there are economies of scale (larger size is less costly) to the point that the minimum efficient size firm is a substantial portion of the market. In automobiles, for example, minimum efficient sizes are large enough that it is doubtful that there could be more than a dozen or so mass-market automobile companies world-wide.

What monopolies do (that we don't like)

• Restrict output and raise price– Transfer income to themselves, a distributional issue.– Efficiency is lost, because society forgoes the

opportunity to turn relatively low value resources into relatively high value products.

• Allow costs to rise, thanks to lack of competitive pressure. (Allocation issue.)

• Retard or distort innovation, to defend the monopoly. (Allocation issue.)

• Concentrate political power.

Antitrust laws

Laws against monopolies in the United States:

• Sherman Act of 1890 • Clayton and Federal Trade Commission Acts of

1914.

Sherman Act

• The Sherman Act of 1890 makes it illegal to "monopolize, or attempt to monopolize, ... any ... trade or commerce..."

• This law is aimed at market structure. The U.S. Justice Department has the responsibility for enforcing this law.

The Clayton and Federal Trade Commission Acts of 1914

• Prohibit monopolistic mergers and certain other forms of anti-competitive behavior.

• These laws are aimed more at conduct. • The Federal Trade Commission was

established by this legislation to enforce this law.

Justice Dept. and the FTC

• That's why we have two government agencies, Justice and the Federal Trade Commissin, involved in antitrust law enforcement.

• In the 1990’s, for example, it was the FTC that required Columbia/HCA to sell its Aiken hospital when it acquired a hospital in Augusta.

• Also back then, the Justice Department sued two hospitals in Dubuque, Iowa, that were merging to form a local monopoly.

“Antitrust”• Calling anti-monopoly laws "antitrust" has its roots in the 1880's. • The "trust" was a specific form of corporate organization used by

Standard Oil as it grew by merger towards being a national oil refining monopoly. Stockholders in corporations joining Standard Oil gave their shares of stock to Standard Oil. In return they got trust certificates giving them part ownership of Standard Oil.

• State courts declared this arrangement illegal under then-existing state corporation law.

• Standard Oil might have had to break up, but New Jersey came to its rescue by legalizing the holding company, allowing New Jersey corporations to own shares in other corporations. (Today, every state allows this.)

• Standard Oil dumped the trust form of organization, moved its corporate headquarters to New Jersey, and became a holding company.

• Nevertheless, the press applied the term "trust" to all large firms that were attempting to monopolize their markets, and the term has stuck to this day.

State antitrust exemptions

• McCarran-Ferguson act asserts Congress’s power to regulate insurance (all types).

• Says that the Sherman Act does not apply to insurance in states that regulate insurance.

• Exemption of state-regulated industries from antitrust law is why Palmetto Health Alliance has a Certificate of Public Advantage.

Measuring structure

The concentration ratio • is the portion of the market controlled by the

top X number of firms. • You choose the X. • Pretty straightforward, if you have market

share data.

Concentration ratio example – Columbia-area hospitals 1995

Measuring structure

• The Herfindahl-Hirschman Index (HHI) • The HHI measures concentration with the sum

of the squares of the market shares of all the firms in the market.

• An HHI near 0 indicates that no firms are large relative to the market -- a competitive structure.

• An HHI of 1 means that there is just one firm in the market -- a monopoly structure.

HHI for Palmetto Health merger

Palmetto Health’s Certificate Of Public Advantage

• Revenue per patient* will not rise faster than inflation

• Will not monopolize medical practice• Savings given to community – Savings were anticipated from reduced

duplication, spreading fixed cost over more patients

• * adjusted for case mix

COPA irony

• A COPA must be actively enforced by the state. • Otherwise, a Federal court might find that the

COPA was not being strictly enough enforced to provide immunity from Federal antitrust action.

• Hospitals "will be forced to monitor and even encourage active state participation as a security measure against antitrust liability."

• Palmetto Health finances its own regulation, by giving DHEC money to pay for independent audits of PHA’s COPA compliance.

Diagnosis-Related Groups for Hospital Payment

• Medicare introduced DRGs in 1983, phasing it in through 1988. SC Medicaid adopted DRG-based payment in 1986. Modified to hybrid system in 1987.

• DRG-based prospective payment puts every patient into one of about 600 DRGs, according to the patient's diagnoses.

• The DRG determines the payment to the hospital (except for very long stay outliers).

Diagnosis-Related Groups for Hospital Payment

• Each DRG has a "weight" that represents the cost of treating such a patient relative to the average of all patients.

• Payment = (The dollar amount for a DRG with weight = 1) multiplied by the weight of patient’s DRG.

• Adjusting one dollar amount adjusts all the payments.

SC Medicaid shortly after DRG’s started

391 Normal newborn 0.2883 $364.12

390Neonate with other significant problems 0.8347 $1,054.23

389Full term neonate with major problems 1.1672 $1,474.17

• OBS DRG DIAG1 DIAG2

• 1 391 V3000• 2 391 V3001• 3 391 V310• 4 391 V3000 605• 5 391 V3000 7661• 6 391 V3000• 7 391 V3001• 8 391 V3001 7661• 9 391 V3000 605• 10 391 V3000• 11 391 V3001• 21 391 V3000• 22 391 V3000• 23 391 V3000 7746• 24 391 V3101• 27 391 V3000 7746• 28 391 V3000 7661

• OBS DRG DIAG1 DIAG2 DIAG3 DIAG4 DIAG5

• 1 390 V3000 7525• 2 390 7786 7660• 3 390 V301 7526 V718• 4 390 V3000 7526• 5 390 V3101 7784• 6 390 V3000 4279• 7 390 V3000 37205• 8 390 V3000 76408• 9 390 V3000 7526• 10 390 V3000 7706• 11 390 V3001 71965 7706 7746• 12 390 V3000 7661 74910• 13 390 V3000 7793• 14 390 V3000 7706• 15 390 V3000 75501• 16 390 V3001 7526• 17 390 V3001 V718

• OBS DRG DIAG1 DIAG2 DIAG3 DIAG4 DIAG5

• 1 389 V3000 7701• 2 389 V3001 7731• 3 389 7701 7718 V3001 0389 7792• 4 389 7718• 5 389 V3001 7708 5531• 6 389 V3000 76408 7731• 7 389 V3000 7661 7731• 8 389 V3101 7731• 9 389 V3000 7731• 10 389 V3000 7731• 11 389 V3000 7454• 12 389 V3000 7708• 13 389 V3001 7731• 14 389 7756 7824• 15 389 V3001 7708 7718 75462 7746• 16 389 V3001 7795 7863 7706• 17 389 7732 7526