M. Gregg Bloche, M.D., J.D.Expertise:
Competition / Markets; Ethical Dilemmas and Allocation of Resources; Health Care Inequalities | Rationality and Consent in the New Medical Marketplace
Award Year: 1996 Show AbstractConflicts have erupted among patients, providers, and payers as a result of the market-driven transformation of the American health care system. These are playing out in coverage decisions by payers, selective contracting between plans and providers, tort liability cases, disclosure and consent issues, and the protection of health information privacy. Dr. Bloche develops an analytic framework to explore the moral, social, and institutional tensions underlying legal conflicts in health care delivery. He studies the problematic character and conflicting interpretations of rationality and consent as bases for ordering relations between patients, providers and payers. Building upon the paradigms of bounded rationality and relational contracting, he draws from the growing legal, economics and psychology literature on incomplete rationality and informal dispute processing mechanisms. His findings propose an array of approaches to the resolution of disputes arising from the growth of managed care. |
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Lawrence Casalino, M.D., Ph.D.Expertise:
Competition / Markets; Managed Care; Organization of Care; Physician Practice Arrangements | Public Policies, Private Policies, and the Organization of Physician Practice
Award Year: 1999Show Abstract Most policy efforts are directed toward patients' rights and trying to improve competition among HMOs. While physician practice organization and physician-health plan relationships are beginning to receive more attention, there has not yet been a systematic study of the institutional effects on these fundamental components of medical care. Dr. Casalino develops a conceptual framework to study public policy and public and private purchasing decisions and their effects on physician practice organization and physician-health plan relationships. With concepts adapted from institutional sociology to identify and classify public and private policies, he describes the effects of such decisions in 13 metropolitan areas, the 12 sites of the Community Tracking Study of the Center for Studying Health System Change plus Minneapolis, which has an unusual physician-employer coalition direct contracting model. By identifying the interaction among purchasers and providers, the project's results will provide information about the effects of proposed policy changes on organizations and may help to reduce unintended consequences. |
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Martin Gaynor, Ph.D.Expertise:
Competition / Markets | Antitrust Policy and the Transformation of Health Care Markets
with Deborah Haas-Wilson, Ph.D.
Award Year: 1994Show Abstract This study examines antitrust policy in the context of integrated provider networks. While increasing collaboration and integration of medical providers may be consistent with the goal of reducing health care costs, antitrust laws are written to promote and protect competition, not collaboration. Drs. Haas-Wilson and Gaynor take a close look at the role of antitrust policy in ensuring pro-competitive impacts of mergers, network affiliations, joint ventures, contractual arrangements, and health insurance purchasing alliances. A conceptual framework is developed to analyze competitive effects, focusing on: 1) the social welfare impacts of changes in structure and conduct in health care markets; 2) whether changes enhance efficiency or quality, or whether they facilitate collusion and market power; and, 3) appropriate antitrust policy if these changes result in lessened competition and a significant welfare loss. The findings provide policy guidance concerning when consolidation and/or collaboration should be encouraged or prohibited. |
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Deborah Haas-Wilson, Ph.D.Expertise:
Competition / Markets | Antitrust Policy and the Transformation of Health Care Markets
with Martin Gaynor, Ph.D.
Award Year: 1994Show Abstract This study examines antitrust policy in the context of integrated provider networks. While increasing collaboration and integration of medical providers may be consistent with the goal of reducing health care costs, antitrust laws are written to promote and protect competition, not collaboration. Drs. Haas-Wilson and Gaynor take a close look at the role of antitrust policy in ensuring pro-competitive impacts of mergers, network affiliations, joint ventures, contractual arrangements, and health insurance purchasing alliances. A conceptual framework is developed to analyze competitive effects, focusing on: 1) the social welfare impacts of changes in structure and conduct in health care markets; 2) whether changes enhance efficiency or quality, or whether they facilitate collusion and market power; and, 3) appropriate antitrust policy if these changes result in lessened competition and a significant welfare loss. The findings provide policy guidance concerning when consolidation and/or collaboration should be encouraged or prohibited. |
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Mark A. Hall, J.D.Expertise:
Competition / Markets; Insurance; Medical Ethics | The Law and Ethics of Consumer-Directed Health Care
with Carl E. Schneider, J.D.
Award Year: 2004Show Abstract New developments in health insurance, designed in part to contain costs, require patients to take greater responsibility for making medical spending decisions. The mechanisms of this new "consumer-directed health care" model — health savings accounts, high-deductible catastrophic coverage, and tiered provider networks and pharmacy benefits — have broad policy implications that may challenge the doctor-patient relationship, the doctrine of informed consent, the medical malpractice standard of care, and other tenets of health care law and ethics. Co-investigators Mark A. Hall, J.D., and Carl E. Schneider, J.D. seek to better understand how law and ethics can and should respond to consumer-directed health care. Their project, The Law and Ethics of Consumer-Directed Health Care, probes a range of possible effects on medical practice and treatment relationships when cost-sharing by patients plays a greater role in medical decision-making. |
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Peter J. Hammer, J.D., Ph.D.Expertise:
Competition / Markets | Competing on Quality of Care: Comparing Antitrust Law to Market Reality
with William M. Sage, M.D., J.D.
Award Year: 1998Show Abstract Although quality has been extensively analyzed in health services research, its role in competition policy has not been elucidated. The purpose of this project is to evaluate the potential for competition policy to protect and improve health care quality, and to determine how best to structure oversight of a competitive marketplace, encouraging appropriate tradeoffs between price and quality. Drs. Sage and Hammer approach these problems through the lens of antitrust law, the government's principal tool to promote competition in health care and other industries. They examine the health care regulatory environment and specific aspects of regulation designed to further noncompetitive goals such as community rating laws, tax subsidies, and entitlements. Changes to antitrust law and the surrounding regulatory environment are prescribed, attempting to resolve trade-offs between price and non-price competition, and between competitive and noncompetitive objectives in current health law and policy. |
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Richard Kronick, Ph.D.Expertise:
Competition / Markets; Insurance | Partially Managed Competition: How Much is Enough?
Award Year: 1998Show Abstract Public policy, at the federal and state levels, assumes that competition among health plans will produce increased value for consumers. But the managed competition theory on which much of this is based assumes that the market would, in fact, be managed. In reality, neither large employers nor government payers are fulfilling their roles as sponsors and fully managing competition as the theory suggested they should. This project measures the extent to which competition is being managed and analyzes why competition is only partially managed based on a review of the literature and interviews with sponsors, and consultants, regulators, and insurance underwriters. Dr. Kronick expects to increase awareness of the extent to which the theory of managed competition and the reality of sponsor behavior diverge. His work should contribute to our understanding of the prospects and limits for the partially managed marketplace to improve quality and efficiency in health care delivery. |
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Mark V. Pauly, Ph.D.Expertise:
Competition / Markets; Insurance | How Well Does Employment-Based Health Insurance Pool Risk?
Award Year: 1995Show Abstract Private employment-based insurance pools some of the risk of high medical care expenses across individuals. How well it achieves protection against risk is not well known, but belief that pooling is imperfect especially for employment-based coverage furnished by small groups supports many actual and proposed insurance regulations, reforms, tax advantages, and explicit subsidies. Dr. Pauly undertakes an in-depth analysis of what is currently known about pooling risk in general and for firms of different sizes and workers of different characteristics. New information is generated on the level of pooling and its variation across firms and industry. The impact of government intervention, such as state insurance regulations, tax subsidies, and ERISA are examined. Knowing how well the current system works and where it functions with different degrees of effectiveness is highly useful to the design of minimally intrusive and cost-effective regulations to improve the efficiency and equity of the market. |
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Mark A. Peterson, Ph.D.Expertise:
Competition / Markets; Politics and Policymaking | Dynamic Institutions and National Health Care Policy Making
Award Year: 1994Show Abstract Beginning with the New Deal, Dr. Peterson explores the ways in which political and governmental institutions respond to the stimulus for public action, direct the choice of policy alternatives, and are influenced by various leadership activities. In related projects, two distinct patterns of health care policymaking are studied. The first concentrates on systemic policy change, assessing the debate over comprehensive health care reform in the context of past failures. It emphasizes the role of macro-level changes in interest groups, Congress, legislative political parties, and the presidency in explaining both the enhanced prospects of comprehensive reform in the 1990s and barriers to change. The second deals with normal policy, investigating health policy ranging from incremental adjustments like direct reimbursement of nurse practitioners under Medicare to major issues, such as AIDS. In this realm, the explanation of policy outcomes emphasizes the role of micro-level interactions among elected and non-elected public officials, interest groups, policy specialists, and activists, which vary across policy communities and over time. |
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James C. Robinson, Ph.D.Expertise:
Competition / Markets; Insurance; Organization of Care; Physician Practice Arrangements | An Institutional Economics of Health Care System Integration
Award Year: 1993Show Abstract This project results in a conceptual framework for understanding the transformation of the health care delivery system from a fragmented cottage industry to a competitive market of integrated delivery systems. Detailed case studies of the leading health care organizations in California are developed with emphasis placed on the evolving relationships between primary care physicians, specialists, and hospitals. The strengths and weaknesses of alternative methods of coordination for each type of provider and facility including unified ownership, joint ventures, complex contracting, and arms-length purchasing are evaluated. Particular attention is given to financial and non-financial incentives pioneered by integrated delivery systems to promote cost-consciousness and continuous quality improvement by physicians. The study builds on the core concepts of new institutional economics including principal-agent models and transactions cost economics and applies them to the health care sector. |
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William M. Sage, M.D., J.D.Expertise:
Competition / Markets | Competing on Quality of Care: Comparing Antitrust Law to Market Reality
with Peter J. Hammer, J.D., Ph.D.
Award Year: 1998Show Abstract Although quality has been extensively analyzed in health services research, its role in competition policy has not been elucidated. The purpose of this project is to evaluate the potential for competition policy to protect and improve health care quality, and to determine how best to structure oversight of a competitive marketplace, encouraging appropriate tradeoffs between price and quality. Drs. Sage and Hammer approach these problems through the lens of antitrust law, the government's principal tool to promote competition in health care and other industries. They examine the health care regulatory environment and specific aspects of regulation designed to further noncompetitive goals such as community rating laws, tax subsidies, and entitlements. Changes to antitrust law and the surrounding regulatory environment are prescribed, attempting to resolve trade-offs between price and non-price competition, and between competitive and noncompetitive objectives in current health law and policy. |
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Mark J. Schlesinger, Ph.D.Expertise:
Competition / Markets; Politics and Policymaking; Public Opinion | Metaphors and Health Policy: The Influence of Public Values and Perception on Policymaking
Award Year: 1993Show Abstract Dr. Schlesinger examines ways in which perceptions and values in the form of four metaphors for health care affect public attitudes and the policymaking process. The metaphors represent four dominant ways in which people view the health care system: 1) as a societal right; 2) as a community responsibility; 3) as a professional service; and 4) as a marketable commodity. The project operates on and tests the belief that Americans formulate their goals for the health care system in terms of these four metaphors, providing the primary standards against which government health policies are judged. It further explores whether the many failures of contemporary policymaking can be traced to flaws in the ways that particular metaphors are linked to policies or to conflicts among competing metaphors. A conceptual framework for interpreting the role of these four metaphors in popular thinking and policymaking is developed through historical review of their role in shaping federal policy as well as application of the model to current health policy issues. |
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J.B. Silvers, Ph.D.Expertise:
Competition / Markets | Health Policy and the Creation, Distribution and Destruction of Value in the Changing Health Care Market
Award Year: 1995Show Abstract Dr. Silvers seeks to better understand what is happening and why in the changing health care environment by following the dollars. He: 1) identifies critical ownership and capital transactions in health care (sales, mergers, and discontinuance of operations); 2) estimates resulting changes in economic value; and 3) assesses the underlying environmental and policy drivers behind industry restructuring. Value-changing transactions are identified by screening private credit reports for health care organizations and utilizing public data of large for-profit firms. Qualifying hospitals, physician practices, nursing homes, home health organizations and HMOs located in four target states are compared with a control group for statistical characteristics, resulting changes in gross economic value, and apparent linkages to environmental and health policy factors. In a refined analysis of market value, selected firms are studied through their public filings and interviews with key executives. Case studies are developed on representative entities in each sector and target state. |
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