Bob Town: 83% of people in MSAs are in concentrated hospital markets (HHI above 2500) and that’s increasing. FTC oversight up. #HealthReform
— Janet Weiner (@weinerja) October 9, 2014
The HHI index for non-wonks is the sum of the squares of marketshare of the top 50 providers in a given market multiplied by 10,000. This is a more sophisticated measure of market power than just counting the number of providers as the same number of providers can lead to very different outcomes in pricing as the example below shows:
Concentrated | Marketshare | HHI Value | Dispersed | Marketshare | HHI Value | |
A | 90% | 8100 | A | 20% | 400 | |
B | 2% | 4 | B | 25% | 625 | |
C | 3% | 9 | C | 15% | 225 | |
D | 3% | 9 | D | 27% | 729 | |
E | 2% | 4 | E | 13% | 169 | |
Total | 100% | 8126 | 100% | 2148 |
The dispersed market with five providers where the biggest provider has no more than 27% of the market is a reasonably competitive market where Econ 101 logic can come into play to a certain extent. The concentrated market where a single dominant provider controls 90% of the market means almost all of the surplus value that could be present in a truly competitive market is captured by monopolistic profits as well as management capture for better hookers and more blow.
My mental model of health care finance is heavily reliant on market power in two seperate markets; payers (insurers) and providers.
If the ratio of ratios is close to one, the providers and payers are evenly matched. If the ratio is significantly above one, providers have a market power advantage as the largest provider groups control a significant chunk of sub-markets that the payers need access to. If the ratio is significantly below one, the payers have market power. They can pressure providers to take low rates.
The above is a simple first step to understanding how prices are negotiated. The second step is an extension of the case where both providers and payers are evenly matched. There are two scenarios where payers and providers are evenly matched.
The first scenario is when the payers and provider are both highly concentrated. This means there is a dominant payer and a dominant provider. The policy impact is that these two groups will butt heads and usually find ways to grab almost all of the potential consumer surplus because individuals buying insurance and groups buying insurance have no other good options and the insurance company has no other option but to contract with the dominant provider group.
The other scenario is that the providers and payers are matched but both are fairly fragmented. In this case, the basic econ 101 analysis actually is useful. Everyone has options and everyone has the ability to shop around for a better deal, so prices are fairly low for both insurance and actual reimbursed medical services.
Obamacare/PPACA is mostly an insurance expansion piece with some provider reform. The insurance expansion piece has several major components that are relevant. The first is that more people can now afford insurance, and insurance has to be offered to everyone. Secondly, the cost of entering the individual insurance market for a carrier has been lowered as the markets are far more predictable now and there is a shared language and platform to seel based on price, network and customer service quality. This is a big deal. And it has led to more insurers on the Exchanges. Competition there is working.
However healthcare reform instead of just health insurance access reform is incomplete. And this leads to a major problem and reform opportunity for the future.
Health insurance as an industry, especially on the Exchanges, will see more players and a diffusion of market concentration. The introduction of co-ops as well as current insurers making plays for new markets that they can understand now is fragmenting the insurance market. However the provider side is still consolidating. The ratio of provider HHI to payer HHI is increasing which leads to providers having more pricing power:
If the ratio is significantly above one, providers have a market power advantage as the largest provider groups control a significant chunk of sub-markets that the payers need access to.
So where are the oppotunties for reform? The easiest and quickest route is for the Federal Trade Commission to aggressively look at any hospital and major provider group consolidation/mergers/expansion in regions where there is already a high level of consolidated provider market power. This theoretically should have broad based political support as it would be pro-free enterprise instead of pro-exisiting business whose leaders and PACS contribute to local officials campaigns. I would imagine that an FTC that aggressively blocks inter-state consolidation moves would get significant political pushback.
The second major route would be similar to the route that systemically significant financial institiutions face now. SIFIs get extra regulatory attention and financial requirements, so major consolidated providers could see significant federal changes. There could be a change in Medicare and Medicaid reimbursement tied to providers whose HHI scores exceed certain thresholds. A small provider could see regular reimbursement rates, a provider entity that is a moderately concentrated group might see a 1.25% cut in Medicare reimbursement while a provider that on its own brings the regional HHI index to over 2500 could see a 3% cut. I don’t know what the numbers or the formula should be, but the basic bet of the policy is to call the bluff of consolidation.
Consolidators often claim that their larger size leads to greater scales of efficiency and expertise which leads to better outcomes and lower net costs. The other viewpoint is that consolidation is an act of monopoly power which leads to either greater profits, better hookers or more blow. So if consolidators believe that they are more efficient, they would still want to consolidate even if they are getting paid less.
Health provider reform is the next opportunity for systemic reform to bring down costs.
Fred Fnord
Providers certainly don’t want this. Do insurers? The current model includes baked-in increase of profits (with the MLR ratio capped, the best way to increase profits is to increase medical expenses and prices.)
If the only one benefiting from this is the consumer, I suspect we’ll be waiting for it for rather longer than we did for ‘universal’ coverage.
Villago Delenda Est
What needs to happen, long term, is that health care is no longer a “business”. It’s a calling, a profession, in which making scads of money for the sake of making scads of money is absolutely its last priority.
Our fucked up Ferengi society needs major retuning.
Roger Moore
Nice theory, but not particularly related to the reality we actually live in. In the real world, the people who are pro-free enterprise are a minority, and the politicians who are pro-free enterprise are an even smaller minority. There’s a lot more work protecting incumbent interests than opening up the market to real competition.
catclub
Where are Medicare and Medicaid in this construction? It could be that BCBS has 90% of the insurance market, but Medicare and Medicaid still dwarf it, right?
Richard Mayhew
@Roger Moore: My understated snark failed :)
Richard Mayhew
@catclub: Let’s keep a real simple model here:
On the Payer side Pre-PPACA in descending order of market share
Medicare
Medicaid (if fee for service and not MCO based)
Big Insurer #1
Big Insurer #2
Medium Insurer #3
Small Insurer #4
Post-PPACA
Medicare (same size)
Medicaid (got a bit bigger through either expansion or woodworkers)
Big insurer #2, lost market share
Big insurer #1 stayed the same
Medium Insurer #3 lost market share
National Insurer #4new to market, grabbed share
National Insurer #5 new to market grabbed share
Co-op #6 new to market grabbed share
Small Insurer #7 stayed the same.
On the provider side, the hospitals either stayed at the same consolidation configuration pre and post PPACA OR Big City Medical Group bought out another hospital and National Hospital Chain bought out two suburban hospitals leading to further consolidation.
Richard Mayhew
@Villago Delenda Est: Okay, how do we get to that point, and what do we do for the system as it is at this time while we are in the process of getting to your desired end point?
Redshift
Nice. Of only our “free market” fundamentalists believed actual free markets, instead of insisting that a free market is one free of any government interference.
catclub
@Richard Mayhew: Thanks!
Liquid
I purchased “Poland” for ten cents at a Yuma, Arizona Salvation Army.
Eric U.
@Richard Mayhew: I’m pretty sure that for the time being, we are going to have to work to keep the ACA as it is, much less improving it. The battle is going to be to implement Medicaid expansion in all the states. Everything else is off the table for right now unless political change happens.
Villago Delenda Est
@Richard Mayhew: I figure in about 35 years a societal collapse that can be directly attributed to unrelenting greed will finally make the point….and we’ll as a society abandon the faux-Smith approach to economics and embrace the real thing.
Until then, I don’t see much hope. The entrenched interests are entrenched.
Richard Mayhew
@Eric U.: Agreed, Medicaid expansion is the big fight for the next five to eight years (I think the money is just too damn good for Texas/Alabama/Mississippi to say no forever).
But provider side reform will be the next system changing reform effort, and I think that fight will happen one way or another in the mid to late 20’s. I want to see markers laid down now so that good policy ideas can be beaten up, revised, refined, and made strong enough to the point where implementation makes sense in twelve or fifteen years.
Bill Arnold
IMO, in 35 years many categories of greed will be dominated by machines which will be inhumanly sophisticated and fast. If we let it happen. (Capping the speed of HFT worldwide would be a good start.)
Bill Arnold
This deserves elaboration.