PM Competitive Strategy: Health Care Monopolies
- Worst Practices to Grab and Retain Monopoly
- Grab the Highest Profit "Cost does not matter" Big Tech Employers
- Hospital Concentration by Predatory Aggression
- Raise Salaries of Doctors to VERY HIGH Levels
- Very highly paid management
- Close down Independent Reviews of Doctors on Yelp
- Making Small Employers uncompetitive - Making harder to Hire!
- Implicit Cooperation in Raising Prices by Entire Industry
- Rising Costs hurt Individual Payers massively
- Rollups leave Insurers No Choice
- Insurance Companies DON'T CARE - Cost plus behavior
- Contracting Policies
- Gag clauses on prices
- Standard of Pricing - compared with Platinum plated Plans
- Bundling of Services - Heavy Profits made on Out-patient, scans, tests at Hospital rates
- Growth in Rural areas by Bundling a regional HMO
- Speciality Concentration - Acquire Smaller "Competitors"
- Boost ROI by focus on clinics, Outsource complex, high Capex for hospitals
- Punitively high out-of-network charges - indirect lowering of costs
- Use Tele-consulting or Tele-radiology
- All our Network or Nothing
- You cannot divert or encourage patients to cheaper providers
- Patient Referral Kickbacks
- Baked in ER visit Surprises
- Cost bloat - outgrow and Concentrate - Examples
- Transparent Pricing, Collective Bargaining and Shopping
- Inefficient Markets Problem
- Laws to promote Transparency
- Hospitals oppose transparency
- Game of Inflating Cash Prices and Background insurer discounts
- Insurers are Middlemen - benefit from opaque prices
- No Cost Accounting - Huge complex of Medical codes and Pricing Loopholes
- Poor Manual vs Automation
- Why not Self service - let patient get savings Not allowed!
- Transparent Pricing helps Service Centers
- Lobbying - Pharma Companies own the House and Senate!
- Opacity in Pricing - - Lack of transparency in medical prices hurts consumers
- Enabling In-health Shopping trends
- Out of Network - voids contracts - puts burden on patient - insurer does not support
- Collective Bargaining by Employers
- Lawsuits to Level the playing field - often with State Attorneys
- Outsourcing to Third-Parties Administrators for Customer Services
- Shopping Networks for Healthcare
Worst Practices to Grab and Retain Monopoly
Grab the Highest Profit "Cost does not matter" Big Tech Employers
Ironic Sutter is seen as the high end. It seems Sutter has outsmarted Kaiser by capturing the most profitable high end tech crowd in Northern Calif.
As an example Kaiser has for decades positioned itself as the vertical integrated lowest cost provider to capture the "family, baby and well-child market". While it costs just a few thousand dollars at Kaiser for last few decades to push out a baby End-to-End and as it optimized hospital stays. However, big tech employers are saying so what .. just ignore.
Hospital Concentration by Predatory Aggression
Sutter Health has gobbled up doctors’ practices across the Bay Area, gaining market muscle that has pushed costs upward. “Sutter embarked on an intentional, and successful, strategy of securing market power in certain local markets.” - CA AG Office
“There are a number of markets in the U.S. that are dominated by one very large, powerful health system .. [After CA AG suit against Sutter] It could be that we’re going to see a new level of activity by state antitrust enforcers looking at competition in their own backyards.” - Martin Gaynor, a health care economist at Carnegie Mellon University
Hospital prices at Sutter and Dignity Health, the two biggest hospital chains in California, were 25% higher than at other hospitals around the state. The giant health systems used their market power to drive up prices — making the average patient admission at both chains nearly $4,000 more expensive. USC study'16
After examining the consolidation of the hospital, physician and health insurance markets in California from 2010 to 2016, UCB authors said 44 of California’s 58 counties had “highly concentrated” hospital markets.
Obstetricians employed by Sutter Health, for example, are reimbursed about three times more for the same service than independent doctors. It’s a key reason why Northern California is the most expensive place in the country to have a baby. - A KHN review of OB-GYN charges on several insurers’ online cost estimators.
Raise Salaries of Doctors to VERY HIGH Levels
The state’s lawsuit said Sutter used its windfall from excessive prices to acquire more hospitals and medical groups. It also enabled Sutter to “bestow extremely high salaries for its officers and upper management,”
If you look at the qualifications of doctors the ones with high "brand name" teaching like Stanford, Harvard tend to be at Sutter facilities. This is starkly different from often the Kaiser "new" doctors who accept new patients - but are mostly from third world countries. Sadly Kaiser insurance rates, high deductibles, etc. don't reflect the HUGE difference in salaries that these qualifications reflect.
Very highly paid management
Patrick Fry, Sutter’s chief executive from 2005 to 2016, had $13.4 million in total compensation during his last year there, according to Sutter’s 990 tax filing for 2016, the most recent year available. Overall, 18 executives at Sutter had $1 million or more in total compensation during 2016, the federal tax filing shows. - SRC
Close down Independent Reviews of Doctors on Yelp
While you can find reviews of most doctors and practices eg on Yelp, the Sutter pages will be present but blank - serving to direct to website and phone number. Essentially Yelp has been shut up and only serves as a marketing pointer.
Making Small Employers uncompetitive - Making harder to Hire!
Another reason big tech doesn't care is they have very young, mostly unmarried employees. So their health costs are already super low. However, this becomes a HUGE benefit for their hiring strategies.
So the class action suit was on behalf of a class of more than 1,500 employer-funded health plans. - Richard Grossman, lead plaintiffs’ lawyer representing the class
It is no wonder the 2019 CA AG Becerra’s lawsuit mirrors a similar civil case filed in 2014 by a grocery workers’ health plan. The issues haven't really changed in 5 years. Grocers need their workers to have health care - same platinum pricing models were screwing them then also.
Implicit Cooperation in Raising Prices by Entire Industry
State lawyers also pointed out that Sutter’s conduct triggered an “umbrella effect” by encouraging other providers to raise their own prices.
Rising Costs hurt Individual Payers massively
Consumer advocates and state lawmakers applauded CA's aggressive action because of the toll high prices take on millions of Californians. Many residents struggle to pay rising insurance premiums and out-of-pocket expenses for emergency room visits or routine hospital tests.
- Consumers bear the burden of these monopolistic activities .. To ensure health care is affordable and accessible to all, we have to get a handle on predatory pricing - State Sen. Ed Hernandez (D-West Covina), chairman of the Senate health committee
Rollups leave Insurers No Choice
Insurance Companies DON'T CARE - Cost plus behavior
Sutter is right that insurance companies are partially to blame for pushing up costs.
CA AG Becerra says Sutter's Contracting Policies have allowed the company to “thoroughly immunize itself from price competition.”
Sutter’s actions “improperly block any and all practical efforts to foster or encourage price competition between Sutter and any rival Healthcare Providers or Hospital Systems,” - CA AG.
Gag clauses on prices
Standard of Pricing - compared with Platinum plated Plans
Sutter countered saying “healthy competition and choice exists across Northern California” for consumers seeking medical care. It also said its charges for an inpatient stay are lower than what other nearby hospitals charge.
Instead of better and cheaper integrated services, it inevitably results in higher prices.
As physicians are subsumed into hospital systems, they can get paid for services at the systems' rates, which are typically more generous than what insurers pay independent doctors. This is because of the far higher negotiating power of these concentrated systems.
Bundling of Services - Heavy Profits made on Out-patient, scans, tests at Hospital rates
Some services that physicians previously performed at independent facilities, such as imaging scans, may start to be billed as hospital outpatient procedures, sometimes more than doubling the cost.
Growth in Rural areas by Bundling a regional HMO
Speciality Concentration - Acquire Smaller "Competitors"
In a structural shift sweeping through health care in the U.S. - large clinics are increasingly acquiring private physician practices.
Boost ROI by focus on clinics, Outsource complex, high Capex for hospitals
Punitively high out-of-network charges - indirect lowering of costs
Consider an out-of-network cardiologist who "consults" for a patient in
In surgeries why is that most anesthesiologists
While hospitals have their own ultrasound, MRI or CT scan equipment, often the technicians who run them are contractors esp. after hours. Their services get billed so much more than staff that they are willing to come in just for 1 scan.
Use Tele-consulting or Tele-radiology
- Entire MRI, CT scans, and imaging services are being run with a large number of machines but not a single radiologist on staff. This is because the "readers" are all out of network.
All our Network or Nothing
Its “all-or-nothing” contract terms that require all of its facilities to be included in insurance networks.
Sutter practices in negotiating Bay Area monopoly - all our rates, all our network
Sutter has an “all or nothing” approach to negotiating with insurance companies, requiring them to include all the company’s hospitals in their provider networks even if it doesn’t make financial sense to do so. Impact is huge as SFO prices are 30% higher than LAX area due to Sutter alone. As a result prices for heart attack costs in SFO cost $25,000 where Sutter operates vs LA where it is $15,000.
- The final Mar 2020 settlement for its court loss in anti-competitive behavior
- Pay $575 million to settle claims to employers, unions and the state and federal governments
- Barred from future so-called “all or nothing” agreements
- Required to limit what it can charge patients for out-of-network services (it had set high prices)
- cease bundling services and products, and switch to standalone pricing
Not have that contracts that bar, now allow insurers and employers to give patients pricing info
What was NOT addressed and why it settled
- Lack of transparency in medical prices
- Most doctors outside Sutter find it extremely difficult to pull EHR patients charts outside of it
- Sutter Health gets to maintain its closed in integrated network
No admission of wrongdoing
Other Legal issues
- Takes local ammunition out of equation in a bigger federal anti-trust fight (fix is in perhaps?)
Lawsuit on sharing medical records without authorization in a large-scale breach of patient data
SRC, NYT, modernhealthcare.com, khn.org, healthcaredive.com
You cannot divert or encourage patients to cheaper providers
One way insurance companies keep costs down is to steer patients to cheaper health care providers through a variety of incentives. Becerra says Sutter Health bans insurance companies from using these incentives, making it harder for patients to use their lower-priced competitors.
Patient Referral Kickbacks
- Nov'19 Sutter and a Sacramento Surgical practice had to pay $46m in US DoJ fines to resolve allegations that doctors received kickbacks to refer patients to Sutter.
Baked in ER visit Surprises
People often are unable to pick which hospital they go to in a medical emergency, which can lead to surprise bills when they learn a hospital or doctor was not in their network.
Cost bloat - outgrow and Concentrate - Examples
Stanford $5b new facilities to be paid off - Platinum plated health care
Kaiser a "Cheap Integrated Secretive HMO" - yet costs as high as Others
Sutter Health a highly profitable "non-profit"
One of California’s largest hospital systems Sutter Health, operates 24 hospitals with 5,500 doctors across Northern California Sutter’s nonprofit health system also has 35 surgery centers, 32 urgent-care clinics and more than 5,000 physicians in its network.
While Sutter Health is a Sacramento-based nonprofit, its assets rose to $15.6 billion in 2016 from $6.4 billion in 2005. It reported net income of $893 million last year on $12.4 billion in revenue.
Sutter has reached a confidential agreement Oct 2019 for final court decision Q1'2020 in a massive class-action lawsuit later joined by California’s attorney general, Xavier Becerra.
The state said its investigation started in 2012 under Kamala Harris, California’s previous attorney general and now a U.S. senator. Six years ago, her office sent subpoenas to several health systems and insurers seeking information about market concentration and its effect on medical prices.
Becerra’s office sought injunctive relief to halt Sutter’s alleged anti-competitive behavior, not monetary damages. But the private litigation brought by a class of about 1,400 self-funded employers sought damages that could exceed $1 billion.
Allegations were that it abused its market power, pursued numerous anticompetitive practices and has been overcharging patients for medical bills. Independent research showed that health care costs in Northern California are higher than elsewhere in the state and said Sutter was largely to blame for the higher costs.
If the state prevails against Sutter it could put “a chill on anticompetitive practices that are being adopted across the U.S. and that could help slow down hospital price increases. That would be good news for consumers.”
Transparent Pricing, Collective Bargaining and Shopping
Inefficient Markets Problem
Health care has VERY non-competitive markets that have defeated policy makers price caps or surprise bills,etc.
Instead of price regulation, the better and more disruptive idea is to actually make markets competitive on price and quality.
Laws to promote Transparency
The Trump administration announced a price transparency rule.
- It requires hospitals to post real prices for 300 common shoppable services.
- The rule also requires public disclosure of the secret negotiated discounts between hospitals and insurers. The hope is that this will shine a light on the current pricing games and ignite competition.
Hospitals oppose transparency
The new Trump rule had no partisan opposition when it was announced, but the American Hospital Association immediately filed a lawsuit to block it, arguing, weirdly that showing prices would confuse patients.
Game of Inflating Cash Prices and Background insurer discounts
The Free Market Medical Association is a consortium of doctors opting out of the game of artificially inflating prices for the purpose of negotiating bigger insurance discounts. Sick and tired of the high cost of medical coding collections, and exhausting appeals, these medical providers are setting true upfront prices.
Insurers are Middlemen - benefit from opaque prices
No Cost Accounting - Huge complex of Medical codes and Pricing Loopholes
In most businesses, the cardinal mantra is not to sell at a loss. For this simple cost accounting that takes into account End-to-End costs of acquisition, production, storage and overhead of customer services, sales and marketing are all taken into account.
However, health providers rely on fat margins and have been focused on other priorities like hiring staff and meeting regulatory requirements. Itemizing their true cost to calculate a real price has never been required by the market. However if they don't understand WHERE the costs really come from, how can they control them?
Insurers and Providers over decades have inherited a badly gamed system of jacking up prices each year for the purpose of offering bigger discounts to insurers. It’s gotten so out of hand that hospitals and insurers now have armies of people to negotiate discounts for bills they themselves can’t interpret.
Poor Manual vs Automation
But often the front office, nurses etc. often exceed the actual "expensive" doctors by 2:1 or 4:1. Considering the average SFO area nurse can make $150,000 pa fully loaded, and the "front receptionists" probably exceed $75,000 pa - any savings in the "checkin" efficiency is likely
Why not Self service - let patient get savings Not allowed!
- Now that patients are using Facebook, and doing online travel reservations all by themselves. why not let them do more of the legwork themselves.
Transparent Pricing helps Service Centers
Price transparency is not the silver bullet to lower health-care costs, but a necessary first step.
Surgery Center of Oklahoma which has impeccable quality, has a set menu of true prices, which do not vary depending on your insurance carrier or employer. Because the center doesn’t spend money on insurance contracting and wrestling over bills, their prices are well below what others charge.
Americans are hungry for honesty in health care as they are tired of surprise bills.
For transparent pricing and competitive centers business is good.
In the past, hospitals scoffed at the idea of agreeing to prices before scheduling services, but now the joke is on them. Medical centers that are not participating in these online marketplaces are losing business to the medical centers that are. In one study, surgery centers that switched to real price transparency reported a 50% increase in patient volume and a 30% increase in revenue.
Lobbying - Pharma Companies own the House and Senate!
An estimate puts 80% of drugs in finished or semi-finished for are imported (at very low costs) from China and India, etc. But the stamp of local pharmas and further refinement and FDA passing, or mainly "MBA-driven" marketing and bean counter processing!
However the large lobbying power of drug makers
- This woman was charged $143,396.66 for a breast biopsy — here are the people working to improve medical billing transparency - MarketWatch
Opacity in Pricing - - Lack of transparency in medical prices hurts consumers
Enabling In-health Shopping trends
- An inhouse CAT scan said inhouse price was $5000 (and costing patients entire deductible in so-called Obamacare Bronze plans), but if booked through MDsave.com same service would be $522 - saving patients the bulk.
Out of Network - voids contracts - puts burden on patient - insurer does not support
Collective Bargaining by Employers
Acting as an employer group, the Pacific Business Group on Health is now using its collective purchasing power to drive greater price and quality transparency by hospitals. It is also creating public accountability.
Lawsuits to Level the playing field - often with State Attorneys
Recently, Pacific Business Group on Health challenged Sutter Health over its extremely high prices, pointing out a number of potentially illegal anti-competitive practices. The California Attorney General Xavier Becerra took the business group’s complaint to court, which resulted in a $575 million settlement by the hospital.
Outsourcing to Third-Parties Administrators for Customer Services
Anthem Blue Cross has greatly cut their internal costs, by requiring third party administrators like CollectiveHealth.com. Unlike 24/7 this uses the web to answer most questions, limiting to 8-5 M-F service only.
Ironically the network, etc. are all the same - and likely the contract rates as well come from the much larger insurer network and negotiating power.
Shopping Networks for Healthcare
These are the equivalent of travel websites that list airline prices.