Reading list

Low-Cost Lessons from Grand Junction, Colorado, by Thomas Bodenheimer.

FTC and DOJ Publish Revised Horizontal Merger Guidelines, Hutton & Williams LLP.

Health Reform and Market Competition: Opportunities and Challenges, by Robert Leibenluft and Harold Luft.

A critique of recent publications on provider market power, by Margaret E. Guerin-Calvert and Guillermo Israilevich. I’m including without endorsement because it references many good papers, though it references some weak ones too. In particular, see footnote 68 for papers on geographic variation of health spending and footnote 70 for a reference to the paper listed below by Vivian Wu. Note also the incorrect interpretation of the literature on cost shifting on page 9 and reference in footnote 13 to methodologically weak studies of that topic (see my survey of all the cost shifting literature). See also David Dranove’s commentary about this paper.

Managed care’s price bargaining with hospitals, by Vivian Y. Wu

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.

Brand Loyalty, Generic Entry and Price Competition in Pharmaceuticals in the Quarter Century After the 1984 Waxman-Hatch Legislation, by Ernst R. Berndt and Murray L. Aitken

The landmark Waxman-Hatch Act of 1984 represented a “grand compromise” legislation that sought to balance incentives for innovation by establishing finite periods of market exclusivity yet simultaneously providing access to lower cost generics expeditiously following patent expiration. Here we examine trends in the first quarter century since passage of the legislation, building on earlier work by Grabowski and Vernon [1992,1996] and Cook [1998]. The generic share of retail prescriptions in the U.S. has grown from 18.6% in 1984 to 74.5% in 2009, with a notable acceleration in recent years. This increase reflects increases in both the share of the total market potentially accessible by generics, and the generic efficiency rate – the latter frequently approaching 100%. Whereas in 1994, the generic price index fell from 100 to 80 in the 12 months following initial generic entry and by 24 months to 65, in 2009 the comparable generic price indexes are 68 and 27, respectively. Recent studies sponsored by the American Association of Retired Persons focus only on brand prices and ignore substitution to lower priced options following loss of patent protection. For the prescription drugs most commonly used by beneficiaries in Medicare Part D, the average price per prescription declined by 21.3% from 2006 to 2009, rather than increasing by 25-28% as reported by the AARP. Finally, we quantify changes over time in the average daily cost of pharmaceutical treatment in nine major therapy areas, encompassing the entire set of molecules within each therapy class, not simply the molecule whose patent has expired. Across all nine therapeutic areas, at 24 months post-generic entry, the weighted mean reduction in pharmaceutical treatment cost per patient is 35.1%.

The Funding Status of Retiree Health Plans in the Public Sector, by Robert Clark and Melinda S. Morrill

While no longer common in the private sector, most public sector employers offer retiree health insurance (RHI) as a retirement benefit to their employees. While these plans are thought to be an important tool for employers to attract, retain, motivate, and ultimately retire workers, they represent a large and growing cost. This paper reviews what is currently known about RHI in the public sector, while highlighting many important unanswered research questions. The analysis is informed by detailed data from states on their liabilities associated with RHI, which were produced in accordance with the 2004 Government Accounting Standards Board Rule 45 (GASB 45). We consider the extent of the unfunded liabilities states face and explore what factors may explain the variation in liabilities across states. The importance and sustainability of RHI plans in the public sector ultimately depends on how workers view and value this post-retirement benefit, yet little is known about how RHI directly impacts the public sector labor market. We conclude with a discussion of the future of RHI plans in the public sector.

How sensitive is physician performance to alternative compensation schedules? Evidence from a large network of primary care clinics, by Lorens A. Helmchen and Anthony T. Lo Sasso

Despite its centrality for the provision of health care, physician compensation remains understudied, and existing studies either fail to control for time trends, cover small samples from highly particular settings, or examine empirically negligible changes in reward levels. Using a four-year sample of 59 physicians and 1.1 million encounters, we study how physicians at a network of primary care clinics responded when their salaried compensation plan was replaced with a lower salary plus substantial piece rates for encounters and select procedures. Although patient characteristics remained unchanged, physicians increased encounters by 11 to 61%, both by increasing encounters per day and days worked at the network, and increased procedures to the maximum reimbursable level.

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