Chapter 02: Competitive Tensions

Growing Tensions in Emerging Health 2.0 Markets

[The Challenging Insurance, Political, IT and Business Ecosystem]

By David Edward Marcinko

By Hope Rachel Hetico

Heights by great men reached and kept were not obtained by sudden flight but, while their companions slept, they were toiling upward in the night – Henry Wadsworth Longfellow

IntroductionHealthcare Market Tensions

Health care reform – as incremental as it has been on both the Federal Medicare and State Medicaid levels – forces medical providers to look for more efficient ways to provide services, as well as additional sources of revenue in a margin-diminishing business model. Total Federal Spending for both programs, under current Obama Administration assumptions about the health costs are growing.

Skepticism is prevalent throughout the healthcare industry about the benefits and the role of market competition in the provision of healthcare services, despite pronouncements by the Federal Trade Commission (FTC) and Department of Justice (DOJ), that competition has positively affected healthcare quality and cost-effectiveness. Recommendations that many of the barriers to competition that prevent it from fully benefiting consumers have beeen, or are being, removed.

And so, according to Cimasi, Alexander, Zigrang and others; this growing economic tension has produced the following innovative health 2.0 business models and methods of reimbursement.

More here: BOOK ORDERS [Pre-Release]:

Dictionary of Health Insurance and Managed Care:


26 thoughts on “Chapter 02: Competitive Tensions

  1. Appendix 1: Popular Patient Blogs

    A Chronic Dose
    A Shot in the Dark
    All Blogged Up: A Moof’s Tale
    Amazing Grace
    Asthma Mom
    Bad Back Blog – Herniated Disc
    Brass and Ivory
    But You Don’t Look Sick?
    Charming BB
    Cushing’s & Cancer
    Diabetes 360
    Diabetes Mine
    Diabetes Technology Blog
    Emanon’s Journey
    Every Patient’s Advocate
    Grief, Loss & Transitions – Journey of Hearts Blog
    It’s a Wonderful Life
    It’s All About the Walls
    Lemonade Life
    Life of a Diabetic
    Life with Leukaemia
    Scott’s Web Log
    Sick Girl Speaks!
    Six Until Me
    Sunshine and Moonlight – A Journey with Multiple Sclerosis
    Survive the Journey
    The Big D — New URL!
    The ICI Experience
    The Preemie Experiment
    The Reality of Anxiety
    The Red Dot Project
    Too Much Brain to Contain
    Your Diabetes May Vary

    Appendix 2: Popular Medical Blogs

    An American Medic in Britain
    Ask a Hospital President — New name and URL
    Balanced Health and Nutrition
    Brain Blogger
    Center on Media and Child Health
    Constructive Medicine 2.0
    Counting Sheep
    Crzegrl, Flight Nurse
    Dare To Dream
    Denver Doc Online
    Doc Gurley
    Doc of Ages
    Doctor & Covenants
    Doctor Pundit
    Dr. Deb
    Dr. Val and The Voice of Reason
    Dr. Wes
    Educated Nobody
    Embrace Your Heart
    Essiewb’s Weblog
    Eye on DNA
    Fat Doctor
    Fertility File
    Girl MD
    Grassroots Science
    Health Management Rx
    Health Train Express
    Healthy Aging For Women
    Highlight HEALTH
    Hope for Pandora
    How I Spent My Nursing Education
    Junkfood Science
    Kate’s Casebook
    Living With Chronic Fatigue Syndrome
    Malaysian Medical Resources
    Medical Executive-Post
    Medicine From The Trenches
    Mexico Medical Student
    Midwife with a Knife
    Musings of a Distractible Mind
    Mutual Aid Based Group
    NICU Parent Support Blog
    Nobody Important
    Not My Second Opinion
    Notes from the Country Doctor
    Nurse Practitioners in Business
    Nursing Assistant Resources on The Web
    Occupational Therapy
    Occupational Therapy Students (B)e(LO)n(G)
    On The Wards
    Other Things Amanzi
    Pediatrics Now
    PICU Traveller
    Prin’s Links for Social Work Students
    Prudence, M.D.
    Raecatherine Almost on the Water
    Raspberry Blase
    Reflections by Dr. Bruce Campbell
    Scan Man’s Notes
    Shrink Rap
    Street Anatomy
    Sumer’s Radiology Site
    Suture for a Living
    The Back Pain Blog
    The Dental Implant Blog
    The Dragonfly Initiative
    The Independent Urologist
    The Intensive Art — New name
    The New Prostate Cancer InfoLink
    The Nurse Practitioner’s Place
    The Nursing Site Blog
    The Palmdoc Chronicles
    The Physician Executive
    The Sterile Eye
    Trauma Bay: Airway, Blog
    Truth In Skincare
    Urban Paramedic
    Vagus Surgicalis
    Vegan Heart Doc
    Veggie Queen Adventures
    Wait Time & Delayed Care
    WardBunny’s Coffee Break
    Why am I still here?
    Yen Rocks the World

    Source: as of January 1, 2010

    Appendix 3: Popular Healthcare Blog Rankings

    1 Kevin, M.D. – Medical Weblog
    2 Highlight HEALTH
    3 GoozNews
    4 The Carlat Psychiatry Blog
    5 Junkfood Science
    6 Diabetes Mine
    7 DB’s Medical Rants
    8 The Covert Rationing Blog
    9 Her Bad Mother
    10 The Doctor Is In
    11 Health Care Renewal
    12 Six Until Me.
    13 Schwitzer health news blog
    14 Disease Management Care Blog
    15 In the Pipeline
    16 Healthcare Economist
    17 Fight Aging!
    18 InsureBlog
    19 Musings of a Dinosaur
    20 Pallimed
    22 ScienceRoll
    24 Brain Blogger
    25 Doctor Anonymous
    26 Retired doc’s thoughts
    27 Beyond Meds
    28 John Goodman’s Health Policy Blog
    29 The Trouble With Spikol
    30 Caustic Musings
    31 The Last Psychiatrist
    32 Fat fu
    33 Weighty Matters
    34 Digital Doorway
    35 Autism Vox
    36 Medicine for the Outdoors
    37 Dr. Deb
    38 Cranky Fitness
    39 CancerDiva
    40 Eye on DNA
    41 Adventures in Autism
    42 Postpartum Progress
    43 soulful sepulcher
    44 Natural Variation – Autism Blog
    45 Autism News Beat
    46 The Voyage
    47 Capital Health WW-MD’s Notes
    48 Brass and Ivory
    49 The Urban Monk
    51 Pinwheels
    52 The Independent Urologist
    53 The Change Blog
    54 HD BizBlog
    55 Kidney Notes
    56 Global Health Policy
    57 Autism Street
    58 Jung At Heart
    59 Big Fat Deal
    60 PixelRN
    61 Women’s Bioethics Project
    62 A Touch of Alyricism
    63 All 4 My Gals
    64 MSSPNexus Blog
    65 Midwife with a Knife
    66 Feed Me!
    68 Healthy Children
    69 Med Law Blog
    70 John McManamy’s SharePosts
    71 How To Use The Law Of Attraction
    72 The Rotund
    73 Creating a Better Life
    74 Teen Health 411
    75 Aging Fabulous
    76 Stayin’ Alive
    77 Facing Autism in New Brunswick
    78 Escape from Obesity
    79 …salted lithium.
    80 lend4health [beta]
    81 Get Ready For Flu
    82 You Already Know This Stuff
    83 hospital impact
    84 ReunifyGally
    85 Bump on the Road
    86 Andrea’s Buzzing About:
    87 Medical Marginalia
    88 Tech Medicine
    89 blog
    90 A Nurse Practitioner’s View
    92 Fighting Fatigue
    93 One Dad’s Opinion
    94 Fat Man Unleashed
    95 Herbal Connection
    96 Big Blueberry Eyes
    97 Slow Down Fast
    100 Dr. Joe Vitale at Zero
    101 Ob/Gyn Kenobi

    Source: Wikio Health, as of January 1, 2010

  2. New ChoiceHealth, Inc is an online comparison shopping marketplace built to provide healthcare consumers a way to save money.

    With consumers can easily locate medical facilities and compare medical procedure costs for services like MRIs, CT scans, mammograms, and more.

    Patients may shop nationwide, or right in their own local market from over 20,000 medical facilities for over 400 of the most commonly performed medical procedures.


  3. Disgruntled Doctors

    Not all physician blogs are geared toward practice information, markets, marketing, competition or medical sensationalism.

    In fact, just the opposite seems to be the case in some extremely candid blogs, like “Ranting Docs”, “White Coat Rants,” “Grunt Docs”, “Cancer Doc,” “The Happy Hospitalist,” “Mom MD”, “Cross-Over Health”, “Angry Docs” and “M.D.O.D.,” which bills itself as “Random Thoughts from a Few Cantankerous American Physicians.”

    According to some of these, they are more like personal journals, or public diaries, where doctors vent about reimbursement rates, difficult cases, medical mistakes, declining medical prestige and control, and/or what a “bummer” it is to have so many patients die; not pay, or who are indigent, noncompliant, etc.

    We call these the “disgruntled doctor sites.” Some even talk about their own patients, coding issues, or various doctor-patient shenanigans.

    Privacy Issues

    But, according to psychiatrist and blogger Dr. Deborah Peel and others, the problem with blogging about patients is the danger that one will be able to identify themselves – the doctor – or that others who know them will be able to identify them.”

    Her affiliation, Patient Privacy Rights, rightly worries that patients might tracked back to the individual, and adversely affect their employment, health insurance or other aspects of life.


  4. An Innovative Primary Care Working-Lab

    For several years, Rushika Fernandopulle MD, MPP and Pranav Kothari MD have been perfecting an innovative primary care practice known as Renaissance Health.

    Serving as a working lab for innovation, the practice provides an unprecedented level of service and access to patients, and has been critically acclaimed both locally and nationally as a medical practice model for the future. Based on several years of research at Harvard University, this new-wave practice embodies several innovative features, including:

    • Time and focus on preventive care and wellness, including comprehensive annual strategic health assessments with proactive planning to provide resources such as nutrition, exercise, stress reduction and other counseling to achieve these goals.

    • Ability to directly contact doctors anytime by phone or email, without having to go through receptionists, nurses or other gatekeepers. Often, these interactions substitute for face to face [F2F] visits.

    • Guaranteed same day, or next day, appointments with no waiting room patients.

    • A full spectrum of resources to help patients play an active role in self-care, including 24/7 access to medical record (either online, on a secure key chain, or on paper), educational material and group visits.

    • Proactive management of conditions rather than simply being reactive.

    • Full performance transparency regarding satisfaction, costs and outcome variables.

    • Optional patient involvement in new services and operations improvement.


  5. On Power to the Patients

    A common rallying cry of the turbulent sixties was “power to the people”. It embodied the zeitgeist of a generation that never seemed content until the democratizing electronic era emerged. In the healthcare space however, power still seems to rest in control of a select few; medical providers, employers, insurance companies, the government and other third-party intermediaries [command and control hierarchy]. Everyone, but the patient, until now [flat or matrix hierarchy]!

    And so, for physicians, nurses, office mangers and medical-executive scions of that era, the founding of, is particularly gratifying. Why? Because Dossia is an independent and nonprofit internet based platform that is personally controlled by patients, and patients alone? It is a voluntary, private, portable, secure, lifelong and decentralized repository of electronic medical information archived from many sources.

    In brief, the mission of Dossia is nothing less than the complete transformation of health information technology, to reduce costs and improve quality, by developing a lifelong personal health record [LPHR].

    Of course, as with any new technology, on may wonder if patients and stakeholders are ready for it? Unfortunately, most are not; but increasingly more are. And, supporters of consumer directed healthcare, concierge medicine, marketplace competition, medical price transparency, direct reimbursement, retail clinics and the like, often respond in the affirmative. Therefore, consider if your private medical practice, clinic or healthcare entity is aware and ready for

    Ready or not, the promise of Dossia [or similar] is complete information about your patient’s medical history — information that they alone control — that will become available whenever needed: for routine office visits, away from home, in an emergency, for hospital admission or after a disaster that could destroy paper records or stand-alone computers. Dossia enables patients to become an active and collaborative partner in their healthcare management. In short, it will allow them to participate in their own care, and:

    * Share information with doctors, clinics, outpatient centers, hospitals and healthcare systems.
    * Avoid delays, mistakes and miscommunication when more than one doctor is involved.
    * Reduce medical communication errors and eliminate waste, costs and redundancy.
    * Track, manage and treat chronic illnesses and enhance evidence-based best practices.
    * More effectively utilize physician and patient-provider face-time.
    * Help family members manage their health care; and more!

    The key feature of Dossia is its personal and private nature. Only the patient is allowed to include or exclude information in a health record, and determine what parts will be shared with others. The patient will choose how much data is collected and how the record is shared – with whom – and in what form. And, while it is recommended patients share a complete medical history with their providers, the decision will always rest with them. Others can not access information without permission, including employers and insurance companies.

    Of course, the Dossia Founders Group is highly suited for this Herculean task. Thus far it includes: AT&T, Applied Materials, BP America, Inc., Cardinal Health, Intel Corporation, Pitney Bowes, sanofi-aventis and Wal-Mart. It is growing and has been endorsed by the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention [CDC] and the National Association of Manufacturers. Initially, Founders will work with Children’s Hospital in Boston, and other qualified experienced vendors to develop and implement the Dossia Network infrastructure.

    Check it out.

  6. Computerworld Speaks to the Healthcare Industry

    Did you ever wish that you could talk to a doctor without schlepping all the way to a crowded medical office where you’ll probably pick up even more germs? Well, if you live in Hawaii, you may be in luck.

    According to Computerworld, January 15, 2009, the Hawaii Medical Service Association (HMSA) just launched a new program where patients can connect with doctors over a standard Internet connection or telephone. The service is available 24 hours a day to anyone in the state.

    Several Medical Specialties Available

    Customers of the insurer pay $10 and non-HMSA members pay $45 per session. About 140 local doctors, including family physicians, cardiologists, ophthalmologists, pediatricians, psychiatrists and surgeons, have signed up to be available for questions.

    Is Hawaii the Vanguard?

    “HMSA’s Online Care is making Hawaii’s health care system more accessible to patients by overcoming the constraints of time, distance, mobility or lack of insurance,” so says Michael Gold, HMSA’s executive vice president and chief operating officer.


    HMSA, an independent licensee of the Blue Cross and Blue Shield Association, also notes that this is the first health plan in the US to provide state residents with online service. Now, we ask, is it coincidental that Hawaii is President-elect Barack Obama’s home state?

    Dr. David Edward Marcinko; MBA

  7. Managed Care Matters

    Joseph Paduda’s weblog on managed care for group health, workers compensation & auto insurance, covering health care cost containment, health policy, health research, and medical news for insurers, employers, and healthcare providers.


  8. Like it or not, DR.Oogle empowers

    A few weeks ago, Stewart Gandolf posted “Social media empowers consumers – including your patients” on his blog, Gandolf’s Marketing Magic.

    Gandolf defines modern branding in dentistry when he concedes, “Consumers are now empowered, and some are getting aggressive.”

    I told Gandolf if one plays to win, losing becomes increasingly less likely.

    I’ve mentioned that I depend on DR.Oogle ( for a steady supply of new patients. It’s the most cost-effective marketing I’ve ever purchased. When I became active in September 2005, there was hardly any competition. I’m glad I got an early start.

    If a dentist has the confidence to ask patients to refer friends and family, it’s only another small step to ask them to put in a good word on the Internet. I suggest that following a pleasant appointment, ask the satisfied customer to put in a good word on the Website of your choice while handwriting the address on a business card. Let the customer know that their opinion is precious enough to go out of your way – to ask them to go out of their way.

    Health 2.0 and Web 2.0 marketing platforms like DR.Oogle become increasingly effective as patient satisfaction data accumulate and more consumers (and competitors) discover the power of numbers. Here’s something that should appeal to any dentist: New patients are sold on my abilities before they walk in the door. Now that’s beautiful. In addition, my staff and I try extra hard to please all our patients. It became habit.

    Empowered consumers on computers are more critical for healthcare reform than empowered preferred provider lists. Besides, empowered consumers are here to stay. Sources like Delta Dental only acts like it.

    One more thing: It’s sort of a favor. If you know a Fort Worth dentist, please don’t mention what I said about DR.Oogle …. and you can tell Delta Dental to bite me.

    D. Kellus Pruitt; DDS

  9. Economist says episode payments will bend healthcare cost

    Episode payments – case rates for major acute interventions and chronic conditions – are the best approach for payment reform, according to a University of California economist.

    The episode-of-care-model is the best thus far. A fixed price meal; not an ala carte menu that is selected by the waiter.


  10. To all our Readers

    The New England Journal of Medicine [NEJM] recently said that 50% of physicians will leave medicine because of ObamaCare. But, we feel it’s more likely the number of practicing physicians [as reflected by our client cohort] will shrink by less than 25% due to fiscal insecurity and a general lack of transferable business skills.

    Nevertheless, this passive strategy may force Congress to boost payments to physicians to keep them in Medicine and to get them to accept more Medicaid and Medicare beneficiaries [in the short term].

    We trust this book, and our active professional consulting services, will help all our colleagues for the long-term.

    What do you think?

    Dr. David Ewdard Marcinko; MBA

  11. Dr. Marcinko,

    Unfortunately, many believe that the impact of newer more theoretical competitive models of medical practice, like consumer-directed health care, medical homes, micro-practices and the deployment of health information technology, may actually add to healthcare costs over the next five to 10 years (Congressional Budget Office).

    So do I, as these are all just another layer of costly middle management.


  12. Medical Industry Sources of Competitive Information

    a. “Capital Survey of Emerging Healthcare Organizations.” (biannual) Ziegler Securities, Medical Group Management Association, Integrated Healthcare Report and IPA Association of California. 11925 Wilshire Boulevard #315, Los Angeles, CA 90025; (310) 575-4354.
    b. “Control Premium Study.” (quarterly) Houlihan Lokey Howard & Zukin. 1930 Century Park West, Los Angeles, CA, 90067-6802; (310) 553-8871.
    c. “Cost Survey.” (annual) Medical Group Management Association (MGMA). 104 Inverness Terrace East, Englewood, CO 80112; (877) 275-6462.
    d. “Financial Studies of the Small Business.” (annual) Financial Research Associates. 510 Avenue J S.E., Winter Haven, FL 33880; (813) 299-3969.
    e. “Group Practice Survey of Key Medical Management Information.” (annual) American Medical Group Association. 1422 Duke Street, Alexandria, VA 22314-3430; (703) 838-0033.
    f. “Health Care Costs.” (quarterly) DRI/McGraw-Hill. 1200 G St., NW, Washington, DC 20005; (202) 383-2000.
    g. “Health Care Policy Report.” (weekly) Bureau of National Affairs, Inc. 1231 25th St. N.W., Washington, DC 20037; (800) 452-7773.
    h. “Health Law Reporter.” (weekly) Bureau of National Affairs, Inc. 1231 25th St. N.W., Washington, DC 20037; (800) 452-7773.
    i. “Jenks Healthcare Report Top 100” (annual) Jenks Healthcare Newsletters, P.O. Box 7664, Atlanta, GA, 30357; (404) 972-9546.
    j. “Physician Characteristics and Distribution in the US.” (annual) American Medical Association. 515 North State Street, Chicago, IL, 60610.
    k. “Physician Marketplace Statistics.” (annual) American Medical Association. Center for Health Policy Research. 535 North Dearborn Street, Chicago, IL, 60610; (800) 621-8335.
    l. “Practice Management STATS: Quick Reference.” (annual) Practice Support Resources, Inc. Independence, MO 64055; (800) 967-7790.
    m. “RMA Annual Statement Studies.” (annual) Risk Management Association. One Liberty Place, Philadelphia, PA 19103. (800) 677-7621.
    n. “Socioeconomic Characteristics of Medical Practice.” American Medical Association Center for Health Policy Research. 535 North Dearborn Street, Chicago, Illinois 60610; (800) 621-8335.
    o. “Statistics: Medical and Dental Income and Expense Averages.” (annual) National Association of Healthcare Consultants, Society of Medical of Medical Dental Management Consultants, and The PM Group. Corporate Headquarters. 432 N. Saginaw Street, Suite 816, Flint, MI 48502; (810) 234-8852.
    p. “United States Health Care Laws & Rules.” (annual) National Health Lawyers Association. 1120 Connecticut Avenue, N.W., Suite 950, Washington, DC 20036; (202) 833-1105.

    The End

  13. Sources for More References and Readings on Modern Healthcare Market-Place Competition

    Abraham, J.; Gaynor, M.; Vogt, W. B. “Entry and competition in local hospital markets.” Preliminary-Rough draft.
    Anderson, G. F.; Poullier, J.-P. “Health Spending, Access, and Outcomes. Trends in Industrialized Countries.” Health Affairs 18: 3 (May/June 1999): 178-192.
    Anderson, T. “Operating in a Competitive Environment. As Health Plans Offer Patients More Choices, The Latest Technology Can Be Just the Image a Hospital Needs.” Washington Business Journal (11/21/2003).
    Arnould, R., et. al. “Does Managed Care Change the Mission of Nonprofit Hospitals? Evidence From the Managerial Labor Market.” National Bureau of Economic Research (NBER), NBER Working Paper Series, (September 2000): 1 43.
    Barlow, R. D. “Surgical Hospitals Vie for Surgery Center Business. Who Says Inpatient Care Is on the Outs?” Repertoire: (5/03).
    Barrell, J. “Managed Care. Myth, Real About Market Evolution.” Infusion (August, 1999): 14-19.
    Bassing, T. “Playing State’s CON Game. Does Process Benefit the Public — or Stifle Competition?” Business journal: (7/28/2004).
    Bassing, T. “Playing State’s CON Game. Does Process Benefit the public — or Stifle Competition?” American City Business Journals: Birmingham business journal. 5 p.
    Bassing, T. “Playing State’s CON Game. Does Process Benefit the Public — or Stifle Competition.” Birmingham business journal: (Dec. 23, 2002).
    Baumol, W. J. “Do Health Care Costs Matter?” The New Republic (November 22, 1993): 16-18.
    Baumol, W. J. “Social Wants and Dismal Science. The Curious Case of the Climbing Costs of Health and Teaching.” Proceedings of the American Philosophical Society 137:4 (1993): 612-637.
    Becker, S. “Bracing for a Medicare Clampdown on Specialty Hospitals.” Outpatient Surgery (August 2003).
    Becker, S.; Werling, K. “Rough Stuff. Tired of Competition from Surgery Centers, Community Hospitals Are Toughening Their Tactics — And ASCs Are Fighting Fire with Fire.” (accessed 10/2/03) October 2, 2003.
    Bell, J. “Key Health System Prepared to Revoke Doctors’ Credentials.” Business first of Columbus (December 5, 2003).
    Berlin, W. E.; Grimes, O. K.; Shriver, P.C. “Improving Health Care: A Dose of Competition. The July 2004 Joint DOJ/FTC Antitrust in Healthcare Report’s Practical Implications for Hospitals and Physicians.” Health Lawyers News: 24-30.
    Bernstein, A. B.; Gauthier, A. K. “Defining Competition in Markets. Why and How?” HSR: Health Services Research 33:5 (December 1998): 1421-1438.
    Blair, J. D.; Buesseler, J. A. “Competitive Forces in the Medical Group Industry. A Stakeholder Perspective.” Health Care Management Review 23:2 (March 22, 1998): 7-30.
    Brubaker, B. “Medicare Deal Likely to Spark More Health Care Competition.” Washington Post. (November 15, 2003), online ed.
    Buchmueller, T. C.; Feldstein, P. J. “The Effect of Price on Switching Among Health Plans.” Journal of Health Economics 16 (April, 1997): 231-247.
    Burda, D. “Raining on Competition. Florida’s Specialty Hospital Ban Is a Bad Idea for Patients.” Modern Healthcare (July 12, 2004): 1.
    “Business Reality Meets Political Imperative. Competition Loses.” Health Affairs 23:2.
    Butler, S. M. “A New Policy Framework for Health Care Markets. Markets Never Go Away; They Simply Adapt to the Environment Created for Them.” Health Affairs 23:2 (March/April 2004): 22-24.
    Cimasi, R. J. “Improving Health Care. A Dose of Competition.” Healthcare consultant.
    Cimasi, R. J. “The Realities of Rising Healthcare Costs.” Green Bay Press-Gazette (January 19, 1999).
    Cirillo, A. “The Hospital’s strategic Advantage in a Consumer-Driven Marketplace.” Health Leaders. (February 27, 2004).
    “Confronting Specialty Competition. Hospitals Should Consider Both Strategic and Facility Design Approaches.” Healthcare Executive (January/February 2004): 38-39.
    Conn, J. “Physician Owners to Fight Back Against OhioHealth.” Modern Physician. (1/21/04).
    Cunningham, P. J. “Reduced Charity Care and Research Funding Reflect Pressures of Managed Care and Competitive Markets. Physicians More Heavily Involved with Managed Care Plans Tend to Provide Less Charity Care.” American Medical Association:
    Cunningham, P. J.; Grossman, J. M.; St. Peter, R. F.; Lesser, C. S. “Managed Care and Physicians’ Provision of Charity Care.” Journal of the American Medical Association (March 24/31, 1999).
    Dobson, A. “A Comparative Study of Patient Severity, Quality of Care and Community Impact at Medcath Heart Hospitals. Executive Summary — September 2002.” The Lewin Group: 1-3.
    “Does Ambulatory Surgery Center Development Cause Hospital Closures?.” Outpatient Surgery (October 1997).
    Dranove, D.; Ludwick, R. “Competition and Pricing by Nonprofit Hospitals. A Reassessment of Lynk’s Analysis.” Journal of Health Economics 18 (November 1999): 87-98.
    Eddy, D. M. “Performance Measurement. Problems and Solutions.” Health Affairs (July/August 1998): 7-25.
    Ellis, R. P. “Creaming, Skimping and Dumping. Provider Competition on the Intensive and Extensive Margins.” Journal of Health Economics 17 (1998): 537-555.
    Enthoven, A. C. “Employment-Based Health Insurance Is Failing: Now What?. A Strategy, Based on Managed Competition, to Free Employers from the Health Care Cost Spiral and Produce Effective Managed Care.” Health Affairs W3-237-W3-249.
    “FASA Presentation. FTC/DOJ Hearings on Health Care and Competition Law and Policy.” Federated Ambulatory Surgery Association FASA. (March 26, 2003): 1-3.
    Federal Hearings on Health Care Competition Law and Policy Set. (February 20, 2003).
    Feldman, R. D.; Wholey, D. R.; Christianson, J. B. “HMO Consolidations. How National Mergers Affect Local Markets.” Health Affairs 18: 4 (July/August 1999): 96-104.
    Fletcher, R. H. “Who Is Responsible for the Common Good in a Competitive Market.” Journal of the American Medical Association (March 24/31, 1999).
    Friedman, B. “Commentary. Excess Capacity, a Commentary on Markets, Regulation, and Values.” HSR: Health Services Research 33:6 (February 1999): 1669-1682.
    “From Regulation to Competition. How Some Providers in New York Responded.” New York State Department of Health. Health Care Financing & Organization. Findings Brief 4: 2.
    “FTC and DOJ Issue Report on Competition and Health Care.”
    “FTC Chairman Announces Public Hearings on Health Care and Competition Law and Policy to Begin in February 2003.” Federal Trade Commission and competition in the delivery of health care
    FTC DOJ Hearings on Health Care and Competition — MedCath Presentation.
    Galloro, V. “Behavioral Modification. Researchers Continue to Study the Reverberations of a For-Profit’s Entry into a Hospital Market. The Findings Are Definitely Mixed.” Modern Healthcare: 32-36.
    Gal-Or, E. “The Profitability of Vertical Mergers Between Hospitals and Physician Practices.” Journal of Health Economics 18 (1999): 623-654.
    Gee, P. “Are You Ready for ‘Big Box’ Health Care?” Health Leaders. (September 27, 2004).
    Gerson, S. M. “FCC v. Butterworth. Positive Economic Effects of Hospital Merger Trump Antitrust Theory.” Health Law Digest 24: 11 (November 1996): 3-7.
    Ginsburg, P. B. “Competition from Specialty Facilities: Is It a Positive for Health Care?” Presentation to Council on Health Economics and Policy.
    Gold, M. “Can Managed Care and Competition Control Medicare Costs? It Will Take More Than Managed Care and Competitive Options to Ensure That Medicare Can Meet Its Obligations in the Future.” Health Affairs W3: 176-188.
    Gordon, J. “Crisis or competition?. Hospital officials voice concern that specialty centers erode profits.” Business first: (9/8/03): 4 p.
    Gordon, J. “Crisis or Competition?. Hospital Officials Voice Concern That Specialty Centers Erode Profits.” Business First: (9/8/03), 4 p.
    Gowrisankaran, G.; Town, R. J. “Competition, Payers, and Hospital Quality.” HSR: Health Services Research 38:6 (December 2003): 1403-1421.
    Graham, J. “The Federal Trade Commission and Physician Practice.” Medical Practice Management (March/April 2005): 259-262.
    Greenberg, W. “Marshfield Clinic, Physician Networks, and the Exercise of Monopoly Power.” Health Services Research 33:5 (December, 1998): 1461-1476.
    Gresenz, C. R.; Rogowski, J.; Escare, J. J. “Updated variable-radius measures of hospital competition.” Health Services Research 32:2: 417-430.
    Gruber, J. “The Effect of Competitive Pressure on Charity. Hospital Responses to Price Shopping in California.” Journal of Health Economics 38 (July 1, 1994): 183-212.
    Guadagnino, C. Ph.D. “Cancer Center Competition Intensifies.”
    Haas-Wilson, D.; Gaynor, M. “Increasing Consolidation in Healthcare Markets. What Are the Antitrust Policy Implications?” Health Services Research 33:5 (December 1, 1998): 1403-1419.
    Halvorson, G. C. “Health Plans’ Strategic Responses to a Changing Marketplace.” Health Affairs 18: 2 (1999): 28-29.
    Hill, S. C.; Wolfe, B. L. “Testing the HMO Competitive Strategy. An Analysis of Its Impact on Medical Care Resources.” Journal of Health Economics 16 (June 1, 1997): 261-286.
    Hirth R.A.; Chernew M.E.; Orzol S.M. “Ownership, Competition, and the Adoption of New Technologies and Cost-Saving Practices in a Fixed-Price Environment.” Inquiry 37:3 (Fall 2000): 282-94.
    “Hospital Competition Can Be Good for Your Health.” Business Wire.
    “Hospital Litigation. More Hospitals Sue Other Hospitals, Claim Antitrust Breaches, Network Exclusion.” Health Law Reporter 10:14 (4/5/2001): 529-531.
    “Hospital Responses to Physician Competition.” Horty Springer Whitepaper, Horty Springer Publications (2003).
    “Hospitals Voice Concerns at FTC-DOJ Hearing on Competition.” AHA News (March 26, 2003).
    Iglehart, J. K. “Business Reality Meets Political Imperative. Competition Loses.” Health Affairs 23:2 (March/April 2004): 7.
    Iglehart, J. K. “Physicians As Agents of Social Control. The Thoughts of Victor Fuchs.” Health Affairs 17:1 (January/February 1998): 90-96.
    “Innovation, Competition Stifled by Hospital Group Purchasing Schemes. FTC, Justice Department Urged to Curb ‘Continuing Marketplace Abuse’.” Medical Device Manufacturers Association: see (September 29, 2003).
    Jacobi, J. V. “Competition Law’s Role in Health Care Quality.” Annals of Health Law
    Kahn, C. N.; Cohen, J. “Adverse Effect of Physician-Owned Limited Service Facilities. Healthy Competition Depends on Level Playing Field.” Council on Health Care Economic and Policy Conference on Specialty Hospitals, Ambulatory Surgery Centers and General Hospitals.
    Keeler, E. B.; Melnick, G.; Zwanziger. “The Changing Effects of Competition on Non-Profit and For-Profit Hospital Pricing Behavior.” Journal of Health Economics 18 (November, 1999): 69-86.
    Kronick, R.; Gilmer, T. “Explaining the Decline in Health Insurance Coverage, 1979–1995.” Health Affairs 18:2 (1999): 30-47.
    Lave, J. R.; Peele, P. B.; Black, J. T.; Evans, J. H., III; Amersbach, G. “Changing the Employer-Sponsored Health Plan System. The Views of Employees in Large Firms.” Health Affairs 18:4 (July/August 1999): 112-117.
    “The Level Playing Field.” ASHA News, see (5/01/03), 3 p.
    Long, S. H.; Marquis, M. S. “Pooled Purchasing. Who Are the Players?” Health Affairs 18:4 (July/August 1999): 105 111.
    Lynk, W. J.; Longley, C. S. “The Effect of Physician-Owned Surgicenters on Hospital Outpatient Surgery. What Can Happen When a Hospital’s Staff Physicians Become Its Business Rivals.” Health Affairs 21:4 (July/August 2002): 215-221.
    Lynk, W. J.; Neumann, L. R. “Price and Profit.” Journal of Health Economics 18 (November, 1999): 99-116.
    Lynn, G. “Perspectives on Competition Policy and the Health Care Marketplace. Single Specialty Hospitals.” (accessed 10/2/03) (Mar. 27, 2003).
    Lynn, G. “Perspectives on Competition Policy and the Health Care Marketplace. Single Specialty Hospitals.” Statement of the American Hospital Association before the Department of Justice and Federal Trade Commission Hearing (March 27, 2003).
    Madden, C. W. “Excess Capacity. Markets, Regulation, and Values.” HSR: Health Services Research 33:6 (February, 1999): 1651-1667.
    Mallon, T. “Competition Between Hospitals and ASCs. Is the Playing Field Level?” Presentation to Council on Healthcare Economics and Policy, September 10, 2004.
    “Managed Care Industry Profits to Soar 60% in 2000. But Not-For-Profit HMOs Struggle with Big Losses.” PR Newswire:
    “Managed Care Reducing Charity Work, Study Finds.” Center for Studying Health System Change, AAHP. Medical Industry Today:
    Marnhar, B. B.; Lewin, L.S.; Lewin and Associates, Inc. “Physician Supply and Distribution. Issues and Options for State Policy Makers.” Prepared for The National Center for Health Services Research, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services (September 15, 2003): 2.8–2.31.
    “MedPAC: Specialty Hospital Competition Doesn’t Harm Community Hospitals.” American Surgical Hospital Association Press Release, November 18, 2004.
    Melnick, G.; Keeler, E.; Zwanziger, J. “Market Power and Hospital Pricing. Are Nonprofits Different?” Health Affairs 18:3 (May/June 1999): 167-173.
    Morrisey, M. A. “Competition in Hospital and Health Insurance Markets: A Review and Research Agenda. Analysis Information of Both Industries.” Health Services Research (April 2001).
    “Most People Uncomfortable with Profit Motive in Health Care. Many Americans Favor Government-Run Insurance and Health Care Services Provided by Non-Profits or Government.” The Wall Street Journal Online 2:12 (12/4/2003).
    “New Bond Deals Could Align Physicians and Hospitals, Reduce Competition.” Finance Watch (May 23, 2003): 2-3 p.
    Needleman, J.; Lamphere, J.; Chollet, D. “Uncompensated Care and Hospital Conversions in Florida. What Does It Mean for Communities When Hospitals Convert?” Health Affairs 18:4 (July/August 1999): 125-133.
    Nichols, L. M.; Ginsburg, P. B.; Berenson, R. A.; Christianson, J.; Hurley, R. E. “Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence Is Waning. Many Health Care Market Participants Are Now Willing to Consider Strong Governmental Intervention to Repair the Health System.” Health Affairs 23:2 (March/April 2004): 8-21.
    O’Conner, D. “Is the Sky Falling on Physician-Owners. Emboldened by Their Success in Harassing Physician-Owned Surgical Hospitals, Hospital Lobbyists Are Now Lining Up Physician-Owned ASCs in Their Crosshairs.” Outpatient Surgery Magazine (April 2004).
    “OhioHealth Pulls Staff Privileges from Group of Physicians.” Business first of Columbus: (December 19, 2003).
    O’Neil, B. “Surgery Centers and Surgical Hospitals. Make Hay While the Sun Shines.” Today’s Surgicenter (February 2004): 24-25.
    “The Origins of the Specialty Hospital and Reasons for Its Rise.” American Surgical Hospital Association. ASHA News: (5/01/03): 3 p.
    Ozgen, H. “A National Study of Efficiency for Dialysis Centers. An Examination of Market Competition and Facility Characteristics for Production of Multiple Dialysis Outputs.” Health Services Research (June 2002): 1-20.
    Page, L. “Report: Hospital CEOs Expect Rising Competition from ASCs, Others.” (Accessed 8/4/03).
    Pauly, M.V. “Managed Care, Market Power, and Monopsony.” Health Services Research 33:5 (December 1998): 1439 1460.
    “Perspectives on Competition Policy and the Health Care Marketplace.” (February 27, 2004).
    “Physician Ownership of Hospitals. Conflict or Solution?” American Surgical Hospital Association. ASHA News: (5/01/03), 3.
    Pierrot, A. H. “The Surgical Hospital Debate Continues.” Surgicenteronline: (accessed 9/21/03), 4 p.
    Piper, T. R. “Specialty Hospitals. Competition or Cream-Skimming?” Missouri Certificate of Need Program and American Health Planning Association. Presentation Before the National Academy of State Health Policy 17th Annual State Health Policy Conference. August 1–3, 2004.
    Pope, C. “The Innovators. Competitive Pressures Inspire Creativity in Clinical Operations.” MGMA Connexion. (February 2004): 40-45.
    Porter, M. E.; Teisberg, E. O. “Redefining Competition in Health Care.” Harvard Business Review (June 2004).
    Public Citizen Health Research Group. “Hidden Rip-Off in U.S. Health Care Is Unmasked.” Health Letter 15:9 (September, 1999): 1-3.
    “Public Hearings. Federal Trade Commission and Department of Justice Hearings on Health Care and Competition Law and Policy.” Federal Trade Commission.
    “Public Hearings. Health Care and Competition Law and Policy.” Federal Trade Commission.
    “Public Not Served by Threat to Pull Hospital Privileges.” Business first of Columbus: (December 12, 2003).
    Pryor, R. “Competition and Costs.” Modern Healthcare (June 24, 2002): 21.
    Pyrek, K. M. “The Medicare Bill Aftermath. Surgical Hospitals Pick Up the Pieces and Plan Their Strategy.” Today’s Surgicenter (January 2004): 21, 27-28.
    Pyrek, K. M. “Surgical-Hospital Model Powered by Quality of Care, Cost Savings, Ambience.” Surgicenteronline: (accessed 9/21/03), 5 p.
    Reichard, J. “Breaux — specialty Facilities Threaten the Survival of Community Hospitals.” Washington HealthBeat (September 16, 2003): 1.
    Rex-Waller, J. G. Federal Trade Commission and U.S. Department of Justice Joint Hearing on Health Care and Competition Law and Policy.
    Robinson, J. C. “Consolidation and the Transformation of Competition in Health Insurance.” Health Affairs 23:6 (2004): 15.
    Robinson, J. C. “Financial Capital and Intellectual Capital in Physician Practice Management.” Health Affairs (July/August: 7/1/1998): 53-74.
    Robinson, J. C. “The Future of Managed Care Organization.” Health Affairs (March/April 1999): 7-24.
    Rogers, C. “Specialty Hospitals vs. General Hospitals. Healthy Competition or an Uneven Playing Field.” AAOS bulletin: (October 2003).
    Rogers, D. “Medicare Battle Enters New Arena. Split Emerges on Payments As Doctor-Owned Chains Rival Community Hospitals.” The Wall Street Journal:,,SB106843132238462500,00.html (11/10/2003).
    Sage, W. M. “Protecting Competition and Consumers. A Conversation with Timothy J. Muris.” Health Affairs 22:6: 101 110.
    Sage, W. M.; Hyman, D. A.; Greenberg, W. “Why Competition Law Matters to Health Care Quality. Competition Law Is a Bellwether for Changes in the Way Health Care Quality Has Been Understood Over the Years.” Health Affairs 22:2 (March/April 2003): 31-44.
    Schneck, L. H. “Urgent Care Center: Are They Competition or Opportunity.” MGMA Connexion: (accessed 4/3/2006).
    Schneck, L. H. “Urgent Care Centers: Physician Practices Respond to Competition.” Medical Group Management 40:8 (April 15, 2001).
    Shalala, D. E.; Reinhardt Uwe E. “Viewing the U.S. Health Care System from Within. Candid Talk from HHS.” Health Affairs 18:3 (May/June 1999): 47-55.
    Shortell, S. M.; Morrison, E. M.; Hughes, S. L.; Friedman, B.; Coverdill, J.; Berg, L. “The Effects of Hospital Ownership on Nontraditional Services.” Health Affairs (Winter 1986): 97-111.
    Siebenmark, J. “MedPAC Specialty Hospital Report Won’t Silence Competition Debate.” Witchita Business Journal: (accessed 3/28/05).
    Silverman, E. M.; Skinner, J. S.; Fisher, E. S. “The Association Between For-Profit Hospital Ownership and Increased Medicare Spending.” NEJM 341:6 (August, 1999).
    Simon, C. J.; Dranove, D.; White, W. D. “The Effect of Managed Care on the Incomes of Primary Care and Specialty Physicians.” HSR: Health Services Research 33:3 (August 1, 1998): 549-569.
    Smith, S.; Heffler, S.; Freeland, M.; The National Health Expenditures Projection Team. “The Next Decade of Health Spending. A New Outlook.” Health Affairs 18:4 (July/August 1999): 86-95.
    Smith, S.; Freeland, M.; Heffler, S.; McKusick, D.; The Health Expenditures Projection Team. “The Next Ten Years of Health Spending. What Does the Future Hold?” Health Affairs 17:5 (September/October 1998): 128-140.
    “Specialty Hospital Building Boom Threatens General Hospitals. Competition Heats Up for Profitable Cardiac and Orthopedic Services.” Center for Studying Health System Change. (accessed 7/29/03).
    “The Structural Analysis of Industries.” Competitive Strategy: 3-33.
    “System Drops Doc Investors in Specialty Hospital.” Cincinnati business courier: http://www.bizjournals,com/cincinnati/stories/2004/01/19/daily19.html?t=printable (Jan. 21, 2004).
    Taylor, M. “Striking Back at Doc Investors. OhioHealth Pulls Hospital Privileges for Physicians in Largest Revocation to Date.” Modern Healthcare (January 26, 2004): 10.
    Teisberg, E. Olmsted; Porter, M. E.; Brown, G. B. “Making Competition in Health Care Work.” Harvard Business Review (July–August 1994): 131-141.
    Tuohy, C. H. “Dynamics of a Changing Health Sphere. The United States, Britain, and Canada.” Health Affairs 18:3 (May/June 1999): 114-134.
    Van de Ven, W.P.M.M.; Van Vliet, R.C.J.A. “Consumer Information Surplus and Adverse Selection in Competitive Health Insurance Markets. An Empirical Study.” Journal of Health Economics 14 (1995): 149-169.
    Weissman, J. S.; Saglam, D.; Campbell, E. G.; Causino, N.; Blumenthal, D. “Market Forces and Unsponsored Research in Academic Health Centers.” Journal of the American Medical Association (March 24/31, 1999).
    Woolhandler, S.; Himmelstein, D. U. “When Money Is the Mission. The High Costs of Investor-Owned Care.” NEJM 341:6: 444-446.
    Wrenn, B. “Contribution to Hospital Performance: Market Orientation vs. Marketing Effort and Lack of Competition.” Journal of Hospital Marketing & Public Relations 14:1 (2002): 3-13.
    Wysocki, Jr., B. “Regulation or Competition?. States Battle Over How to Get Reasonable, Quality Health Care.” The Wall Street Journal A4 (Tuesday, May 7, 2002).

    The End

  14. Are independent medical practices an endangered species?

    Will a new generation of physicians and business pressures spurred by politics, technology, an aging population, the participatory patient movement and healthcare insurance reform finally converge to wipe out mom-and-pop doctor’s offices as we know them?

    Your thoughts?

  15. On CDHPs

    Advocates of consumer directed health plans (CDHPs) argue that it’s principally the degree third-party payment that should be adjusted. But, if patients directly pay more for their care they’ll make better decisions about what care to buy and how much it is worth.

    Now, there is something to this notion. It’s not obviously wrong. But, it’s not obviously right either. What do you think?


  16. Emerging Healthcare Organizations: [Accountable Care Organizations]

    According to Robert James Cimasi of, the new healthcare reform legislation has proposed the implementations of Accountable Care Organizations (ACOs) as a way to increase efficiency and value, and decreasing the cost of delivering healthcare services.

    While the success of implementing an ACO model is yet uncertain, and procedural and legal issues must be resolved, early pilot operations appear to have given some insight into the potential benefit that ACOs could have on the healthcare system.

    Click to access ACO.pdf

    Ann Miller RN, MHA

  17. Managed Competition

    Princeton PhD economist Alain Enthoven’s 1993 paper in Health Affairs on “managed competition” is almost two decades old (health care markets have changed greatly since then) but not in his prescription for change.

    Of course, some ideas are outdated, but many expressed ideas are still very relevant today and embodied in several provisions espoused by advocates for additional contemporary healthcare reform.

    In fact, we have mentioned the “Father of Managed Care” in all three versions of our textbook; including this newest third edition for 2011: The Business of Medical Practice [Transformational Health 2.0 Skills for Doctors]

    We therefore recommend that every healthcare stakeholder read the paper entirely; and then decide for your-self.


    Hope R. Hetico RN, MHA
    [Managing Editor]

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