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Open Access Publications from the University of California

Scholarly Works (4 results)

  • Article
  • Peer Reviewed
Recent Work (2017)
    • Article
    • Peer Reviewed
    Recent Work (2017)
      • Thesis
      • Peer Reviewed
      UCLA Electronic Theses and Dissertations (2022)

      The United States spends a larger percentage of GDP on healthcare than any other OECD nation, and yet it performs poorly on measures of access, process quality and outcomes relative to other wealthy nations. One hypothesis that may explain the relatively poor performance of the United States' healthcare system per dollar spent is that markets for hospitals, physician services, and insurance are highly consolidated and lack competition. This dissertation contributes to the body of literature seeking to measure healthcare market structure and assess the relationship between this market structure and unit prices, overall spending, and healthcare quality.The first paper in this dissertation, “The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence,” demonstrates market-level associations between vertical integration among hospitals and physicians and higher prices for outpatient care. The second essay, “How Hospital-Owned Physician Organizations are Associated with Healthcare Prices, Expenditures, and Quality,” analyzes vertical integration and prices, quality, and total patient spending, building on the findings of the first essay using physician and hospital level claims data. This study finds that vertical integration is associated with higher levels of annual spending for patients attributed to vertically integrated providers, but interpretation of association between vertical integration and outpatient prices is confounded by pre-intervention trends. Analysis of CMS hospital outcome measures does not show associations between vertical integration at a hospital level and quality. Finally, the third essay, “Automated Delineation of Hospital Market Boundaries in California,” explores geographic market definition in healthcare, an important topic in research and antitrust action, while assessing the application of community detection methods in this field. This study finds that community detection methods group hospitals with higher accuracy than other geographic markets as measured by patient flows and may offer promise for merger screening, research on market concentration, and research on geographic variation in healthcare. The final chapter reviews overarching limitations of the dissertation, outlines directions for future research, and comments on potential policy approaches to promote competition and address the symptoms that may result from highly consolidated healthcare markets.

        Cover page: Three Essays on Market Structure, Competition, Prices, Health Spending, and Quality in the US Healthcare System
        • Article
        • Peer Reviewed
        UC Berkeley Previously Published Works (2021)
        This study assessed the relationship between hospital ownership of physician organizations (known as hospital-physician vertical integration) and facility fees billed to commercial insurers and physician service prices. Healthcare claims came from the IBM® MarketScan® Commercial Database (2012-2016, N = 30,716,800 office visit claims [CPT codes 99211-99215]), and hospital-physician vertical integration measures were from SK&A Office Based Physicians Database provided by IQVIA. Multi-variate, fixed-effect models were used to regress prices on market-level hospital-physician vertical integration; models included geographic market and year fixed effects, claim-level variables, and time-varying market-level variables. Analyses did not find that market-level hospital-physician vertical integration was associated with the billing of facility fees for office visits. However, vertical integration was associated with office visit physician prices for some specialties. A 10-percentage-point increase in vertical integration was associated with a 1.0% price increase for primary care, a 0.6% increase for orthopedics, and a 0.5% increase for cardiology; no such association was found for obstetrics/gynecology or oncology. When comparing metropolitan statistical areas (MSAs) in the bottom quartile of changes in vertical integration from 2012 to 2016 to MSAs in the top quartile, we found the following relative price increases based on predicted values for claims in the top quartile: $1.64 (1.9% of mean 2012 predicted price) for primary care to $2.30 (3.1%) for orthopedics to $3.13 (3.4%) for cardiology. Differences in predicted price accounted for an estimated $45.8 million in additional expenditure on primary care office visits in the top quartile of MSAs in 2016. In summary, market-level hospital-physician vertical integration was positively associated with physician prices for select specialties, but was not associated with changes in the use of facility-fee billing. More evidence on the quality effects of hospital-physician vertical integration is needed, as price increases that are not accompanied by measurable quality improvements should be part of any regulatory review.
          Cover page: The Association between Hospital-Physician Vertical Integration and Outpatient Physician Prices Paid by Commercial Insurers: New Evidence
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