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Updating Competitive Strategy Theory in Healthcare

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By Todd A. Zigrang; MBA MHA ASA FACHE
By Anne P. Sharamitaro; Esq.


Michael Porter[i] is considered by many to be one of the world’s leading authorities on competitive strategy and international competitiveness.  In 1980, he published Competitive Strategy: Techniques for Analyzing Industries and Competitors,[ii] in which he argues that all businesses must respond to five competitive forces.

(1) The Threat of New Market Entrants

This force may be defined as the risk of a similar company entering the marketplace and winning business.  There are many barriers to entry of new market entrants in healthcare including: the high cost of equipment, licensure, requirement for physicians and other highly trained technicians, development of physician referral networks and provider contracts, and other significant regulatory requirements.

Certificate of Need (CON) laws, which require governmental approval for new healthcare facilities, equipment, and services have been in place since they were federally mandated in 1974.  State CON laws create a regulatory barrier to entry.  New medical provider entrants commonly face substantial political opposition by established interests, which is manifested in the CON review process.

(2) The Bargaining Power of Suppliers

A supplier can be defined as any business relationship upon which a business relies to deliver a product, service, or outcome.  Healthcare equipment is a highly technical product produced by a limited number of manufacturers. This reduces the range of choices for providers and can increase costs.

(3) Threats from Substitute Products or Services

Substitute products or services are those that are sufficiently equivalent in function or utility to offer consumers an alternate choice of product or service.  An illustration of this in healthcare would be diagnostic imaging as a substitute for surgery, which is often a more costly and risky option for patients. The threat of less invasive or less expensive diagnostic tests other than diagnostic imaging is relatively small for the near term future.

(4) The Bargaining Power of Buyers

This force is the degree of negotiating leverage of an industry’s buyers or customers.  The buyers of healthcare services are ultimately the patients. However, the competitive force of buyers is manifested through healthcare insurers including the U.S. and state governments through the Medicare, Medicaid, TRICARE, and other programs; managed care payors (e.g., Blue Cross/Blue Shield affiliates); workers’ compensation insurers; and, others.  In addition to the government, many of these healthcare insurers are large, national companies, often publicly traded, commanding significant bargaining power over healthcare provider reimbursement.

(5) Rivalry Amongst Existing Firms

This is ongoing competition between existing firms without consideration of the other competitive forces which define industries. Healthcare providers face pressure from other existing providers to obtain favorable provider contracts; maintain the latest technology; increase efficiencies; and, lower prices.


[i]  A professor of Business Administration at the Harvard Business School, Michael Porter serves as an advisor to heads of state, governors, mayors, and CEOs throughout the world.  The recipient of the Wells Prize in Economics, the Adam Smith Award, three McKinsey Awards, and honorary doctorates from the Stockholm School of Economics and six other universities, Porter is the author of fourteen books, among them Competitive Advantage, The Competitive Advantage of Nations, and Cases in Competitive Strategy.

[ii]  Porter, M.E. Competitive Strategy: Techniques for Analyzing Industries and Competitors. The Free Press, 1980.


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6 Responses

  1. Physician market power

    According to Austin Frakt PhD, there’s vastly more economics literature on the effects of hospital market power than physician market power. So, this working paper by Abe Dunn and Adam Hale Shapiro (ungated pdf) is a welcome contribution.

    Click to access Physician_Market_Power_and_Medical_Care.pdf

    Frakt further says that physician concentration is positively and significantly correlated with service price levels.

    Specifically, a 10 percent increase in the FTHHI [fixed-travel-time Herfindahl-Hirshman Index] will cause about a 1 percent increase in physician fees. Linking this finding to historical survey data discussed in Rebitzer and Vortruba [2011] implies that physician consolidation has caused about an 8 percent increase in fees over the last two decades (1988 to 2008). He also find that health-plan concentration is inversely correlated with service price fees. That is, insurance carriers in more concentrated health insurance markets pay lower fees to physicians.

    He also finds a price elasticity of supply in the range of 0.27 to 0.34 for orthopedists and 0.57 to 1.26 for cardiologists. While in most markets an upward sloping supply curve would be unsurprising, in the health service market, this means that physicians treat patients according to service price levels.

    In other words, a physician with a higher price-cost margin will perform more services. On the demand side, he finds a service price elasticity of demand in the range of -0.32 to -0.43 for orthopedics and -0.05 to -0.28 for cardiology patients. This finding supports prior research which suggest that patients are price sensitive, but relatively inelastic (Manning et al. [1987] and Keeler and Rolph [1988]).

    Ann Miller RN MHA via Austin Frakt PhD


  2. Market power makes healthcare “least consumer-friendly” industry

    Concentrated economic power, combined with fee-for-service incentives, has made healthcare “the least consumer-friendly” U.S. industry and enabled arbitrary and capricious price gouging, according to the man behind Time magazine’s “Bitter Pill” feature.




  3. On Competition

    According to Austin Frakt PhD, Health Affairs just published four insightful articles about the growing challenge of provider concentration. As Paul Ginsburg and Gregory Pawlson frame the problem”

    “[C]onsolidation within the health care industry is a double-edged sword: The integration of hospitals, physicians, and others across care settings has the potential to improve clinical quality and increase efficiency, but the consolidation of practices can also increase providers’ market power and thus their ability to command higher prices. Even before the enactment of the Affordable Care Act (ACA) in 2010, the tendency for health care providers to merge and affiliate with each other was increasing. Since then, the pace of consolidation has quickened.”

    “The ACA’s payment reform provisions, such as those related to accountable care organizations (ACOs) and bundled payment, have sent strong signals to providers to pursue clinical integration. Some of the desired integration can be achieved without mergers. Nonetheless, hospital mergers in 2010–12 increased by 25 percent, compared to 2007–09.”


    More: http://thehealthcareblog.com/blog/2014/06/13/how-much-market-power-do-hospitals-really-have/



  4. Provider Concentration and Antitrust Implications

    The first two installments of this three-part Health Capital Topics series on concentration in the healthcare industry focused on the consolidation of health systems and hospital acquisition of insurers.

    This third and final installment will focus on healthcare provider concentration and associated antitrust implications. The consolidation of healthcare providers has been a growing trend since the passage of the ACA. Partly due to the ACA, which incentivizes quality healthcare, in contrast to the quantity of healthcare services provided, many hospitals are merging with other healthcare systems to create organizations capable of managing population health to better handle the operational needs and expenditures required to meet these goals.

    Antitrust enforcement has become a common response in efforts to minimize anti-competitive activities in healthcare markets.

    Click to access ANTITRUST.pdf

    Robert James Cimasi; MHA ASA FRICs MCBA AVA CM&AA CMP™


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