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Competition Policy and Organizational Fragmentation in Health Care
Electronic copy available at: /abstract=1395792
Competition Policy and Organizational Fragmentation in Health Care
Thomas (Tim) Greaney*
Once upon a time and a very good time it was, advocates for market based approaches to
health policy had a coherent story to tell. Cost and quality would remain suboptimal as long as
fee for service medicine persisted and the myriad market imperfections that impede efficiency
went unchecked. Things could be righted however by adopting principles associated with
managed care together with pursuing sensible antitrust enforcement and government
deregulation to clear away the private and regulatory underbrush obstructing market forces.
Economic theorists and policy experts agreed that these steps would effectively address
information, agency, and moral hazard problems and begin to glue together the pieces of our
fragmented delivery system. And, for a while, things seemed to work out as promised.
Providers began to reorganize into firms and other integrating arrangements and health insurers
adopted financial and contractual measures designed to align provider incentives with consumer
needs. Regulators directed policies at removing obstacles to competition and antitrust enforcers
sought to encourage efficient consolidation while blocking cartels and provider oligopolies.
Spiraling costs leveled off for a while and both payment systems and provider organizations
began to adapt to market forces.
But things changed. A powerful backlash against managed care (precipitated in part by
insurers’ short-sighted and sometimes abusive tactics) gave rise to regulations that undermined
some of the methods managed care had used effectively while payors voluntarily withdrew from
active involvement in care management. Managed care and the competition-enhancing practices
it had begun to spawn -- integration and rivalry-- unraveled. Several important lessons for
competition policy emerge from the demise of
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