Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

BACKGROUND

Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES

We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN

With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS

A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES

Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.

RESULTS

Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS

After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Variation in tiered network health plan penetration and local provider market characteristics

OBJECTIVE

To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration.

DATA SOURCES AND STUDY SETTING

We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013-2017 Massachusetts All-Payer Claims database.

STUDY DESIGN

Linear regressions were used to estimate associations between TNP and local provider market characteristics.

DATA EXTRACTION

We constructed measures of TNP penetration and local provider market characteristics and linked these data using three-digit ZIP code.

PRINCIPAL FINDINGS

TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three-digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration.

CONCLUSIONS

Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.

Can increasing technological complexity help strengthen regional economic resilience?

Improving regional economic resilience through technological innovation has always been a strategic focus of China, but the previous studies have paid little attention to the impact of structural characteristics of technological innovation on regional economic resilience. Based on the complexity of technology, this study studies the impact and mechanism of technological systems with more complex internal mechanisms on economic resilience. The main findings are as follows: (1) Higher technological complexity is conducive to technological innovation and can improve regional economic resilience; (2) technological complexity needs to be in the appropriate range, and its positive effect shows diminishing marginal effect; and (3) optimizing market competition and absorptive capacity plays a positive role in regulating the relationship between technological complexity and regional economic resilience. This study provides policy implications for implementing innovation-driven development strategy, formulating economic recovery plan, and medium- and long-term sustainable development strategy.

Entry and competition of retail pharmacies: A case study of OTC drugs sales and ownership deregulation1

This study provides new empirical evidence on the changes in competition and entry decisions of pharmacies after regulatory changes. It investigates the development of the retail pharmacy market in Portugal, which underwent major regulatory changes in 2004 and 2007. Sale of OTC drugs and ownership of pharmacies were liberalized while entry restrictions related to market size and the location of new pharmacies prevailed. Our empirical strategy was based on entry models and provided indirect information on the toughness of competition and entry decisions of firms in the market. We estimated and compared the entry thresholds and their ratios before and after liberalization. Such a comparison allows to see if competition got tenser with OTC drugs deregulated. There were three main findings from the study. First, the entry thresholds decreased regardless of the number of pharmacies in the market, suggesting that room for the realization of profits is broader than it was in the past. Second, although the entry thresholds were lower in value, their increase was steeper with each incumbent in 2020, suggesting harsher price competition with new entrants. Third, the current rule of 3,500 patients per pharmacy is likely overly restrictive, pharmacies could break-even even in smaller markets.

Retelling social inequalities in the era of market competition: Review and discussion for sustainable welfare development

As the prevalence of social inequalities has become increasingly evident, the implementation of social welfare policies in countries across the globe has faced considerable obstacles and has not yielded the desired results. In spite of the fact that social welfare policies are formulated to reduce inequalities in society, the recent increase in inequalities has raised questions about whether or not welfare implementation is appropriate to the social context where resource distributions are dominated by economic structure. Inspired by this, the aim of this paper is to echo contemporary perspectives on social inequality and challenges that have contributed to its development under the economic system of market competition. The contemporary matters arising from social inequalities, which include intergenerational inequality, gender-based inequality, health inequality, and education inequality, are examined in accordance with the context of market competition. This would hopefully enable academicians to timely recognize and address ideological and paradoxical social inequalities and welfare development within their society.

How does market competition affect supplier-induced demand? An experimental study

Introduction

This study investigated the impact of competition on supplier-induced demand in medical markets theoretically and experimentally.

Methods

We employed the framework of credence goods to describe the information asymmetry between physicians and patients, and theoretically derives predictions of physicians' behaviors in monopolistic and competitive markets. Then we conducted behavioral experiments to empirically test the hypotheses.

Results

The theoretical analysis revealed that an honest equilibrium would not exist in a monopolistic market, whereas price competition could induce physicians to reveal their types of treatment cost and provide honest treatments; thus, a competitive equilibrium is superior to that of a monopolistic market. The experimental results only partially supported the theoretical predictions, which showed that the cure rate of patients in a competitive environment was higher than that in a monopolistic market, although supplier-induced demand occurred more frequently. In the experiment, the main channel through which competition improved market efficiency was increased patient consultations through low pricing, as opposed to the theory, which stated that competition would lead to physicians' honest treatment of patients through fair prices.

Discussion

We discovered that the divergence between the theory and the experiment stemmed from the theory's reliance on the assumption that humans are rational and self-interested, which means that they are not as price-sensitive as predicted by theory.

Impact of technological innovation on corporate leverage in China: The moderating role of policy incentives and market competition

Due to its capital-related nature, corporate leverage is highly exposed to financial risk, and optimizing corporate leverage is an effective method of mitigating financial risk to maximize corporate value. We use a two-way fixed effects model to examine the impact of technological innovation on corporate leverage using panel data of A-share listed companies in the Chinese manufacturing sector from 2012 to 2020. The results show that technological innovation and corporate leverage exhibit significant heterogeneity in cross-sectional, spatial and temporal dimensions. By further distinguishing between the effects of policy incentives and market competition, we find that the former exerts an "investment crowding out" effect and the latter an "innovation spillover" effect. These factors mitigate the negative relationship between technological innovation and corporate leverage. In general, this study provides empirical evidence for the rational allocation of resources by the Chinese government, the development of innovation capabilities, and the adjustment of leverage by firms from various regions.

The impact of price transparency and competition on hospital costs: a research on all-payer claims databases

Background

Public reporting has been considered effective in reducing health care costs by mitigating information asymmetry in the market as payers have incorporated publicly available information mandates into pay-for-performance programs and value-based purchasing. Therefore, hospitals have faced increasing pressures to provide price transparency. Despite the widespread promotion of healthcare transparency, the effectiveness of public reporting has not yet been sufficiently understood. This study analyzed the impact of transparency policy and competition on hospital costs by taking the state operations of all-payer claims databases (APCDs) as a case of interest.

Methods

We employed a fixed-effects regression, which allows the generation of hospital-specific effects, in accordance with the suggestion by the Hausman test. The study samples comprise nonprofit and for-profit general acute care hospitals in the United States for 2011–2017. The finalized dataset ranges from 3547 observations in 2011 to 3405 observations in 2015 after removing missing values.

Results

We found that hospitals in the states with APCDs tend to bear higher average operating expenses than those without APCDs, which may indicate that states maintaining higher healthcare expenditures are more attentive to a price transparency initiative and tend to adopt APCDs. With regard to competition, the results showed that weak market competition is significantly associated with higher operating costs, supporting the traditional competition theory. However, the combined effect of APCDs and competition did not indicate a significant association with operating expenses. Further investigation showed a continued tendency for a weak intensity of competition to be linked to lower hospital operating costs in states without APCDs. For those located in non-APCD adopted states, market consolidation helped hospitals coordinate care more effectively, economize operating costs, and enjoy economies of scale due to their large size. Similar trends did not appear in APCD-adopted states except for in 2015.

Conclusions

This study observed limited evidence of the impact of APCDs and market competition. Our findings suggest that states need to make multifaceted efforts to contain hospital costs, not solely depending on the rollout of cost information or market competition. Market concentration may lead to coordinated care or cost economization in some cases. Still, the existing literature also demonstrates some potentially harmful impacts of increased concentration in the healthcare market, such as inefficient use of resources, unilateral market power, and deterrence of innovation. The introduction of a price transparency tool may require additional policy actions that take market competition into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08711-x.

Is Education Beneficial to Environmentally Friendly Behaviors? Evidence from CEOs

Corporate environmental investment decisions play a crucial role in the protection of the public environment. As the decision-maker and executor, the environmental consciousness and social responsibility of the chief executive officer (CEO) has a long-term impact on the company's environmental protection strategy, and the CEO's level of education is a significant factor influencing the CEO's environmental protection decisions. In this paper, we investigate the extent to which CEO education influences environmental protection investment decisions. A CEO education index is constructed as a proxy for CEO education based on the CEO's educational background, using a panel sample of Chinese listed firms from 2010 to 2019 and providing robust evidence supporting the notioin that firms with highly educated CEOs are likely to engage in environmental protection spending activities. However, the positive relationship between CEO education and corporate environmental protection investment is reduced when the CEO also holds the position of chairman. The heterogeneity analysis shows that the positive relationship between CEO education and corporate environmental investment behavior is stronger in non-manufacturing and highly monopolistic market competitive industries. Our study contributes to the sustainability literature by providing a new impetus for corporate environmental activities from the perspective of CEO education and sheds light on the impact of the internal and external factors of firms on the investment in environmental protection. It may also help decision makers to decide whether to hire highly educated CEOs and use a dual structure of CEOs in markets with different levels of competition.

Environmental Risk and Credit Ratings, and the Moderating Effect of Market Competition

This study examines the relationship between environmental risk and corporate bond credit ratings, and the moderating effect of market competition. We focus on Korean firms that are facing increasing risk of environmental crisis after the COVID-19 pandemic. Recently, the Korean government has been controlling businesses while promoting policies to transform the economy into a low-energy, low-carbon economy. We find that a firm’s greenhouse gas emission and energy consumption, which are direct indicators of environmental risk, are negatively associated with bond credit ratings. We also report that the negative effect of environmental risk on credit ratings is stronger in firms with low market competition. This study contributes to prior research by improving the understanding of the effect of environmental risk on credit ratings. In particular, it is significant to examine the effect of environmental risk, measured as direct environmental performance not affected by green washing, on credit rating. Therefore, we shed light on environment-oriented management beyond the determinants of credit ratings, which have been discussed in previous studies. We also suggest that policymakers need to manage market competition in terms of environmental justice, given that market competition has a significant moderating effect on the relationship between environmental risk and credit ratings.

The Effect of Market Competition on the Price of Topical Eye Drops

PURPOSE

To describe the relationship between the number of Federal Drug Administration (FDA)-approved manufacturers and the price change of generic and branded topical eye drops.

METHODS

Retrospective analysis of topical eye drop medications with formulations listed in the FDA Orange Book and the National Average Drug Acquisition Cost database from 2013 to 2017.

RESULTS

The most frequently prescribed generic topical drugs were glaucoma medications (34%), antimicrobials (32%), anti-inflammatories (24%), mydriatics (5%), and anesthetics (5%). The most frequently prescribed branded topical drugs were anti-inflammatories (45%), glaucoma medications (32%), antimicrobials (21%) and dry eye medications (3%). From 2013 to 2017, generic eye drops had a median price decrease of 20% (IQR 32%) while branded eye drops had a median price increase of 44% (IQR 28%) (P < .001). A significant inverse association was identified between the price change of generic eye drops and the total number of all manufacturers (r = -.41, P = .010), generic drug manufacturers (r = -.32, P = .0496), and alternative branded drug manufacturers (r = -.57, P = .002). There was no significant association between the price change of branded eye drops and number of manufacturers. Glaucoma (r = -.58, P = .039) and anti-inflammatory (r = -.69, P = .047) eye drops also had significant inverse associations with the number of generic manufacturers.

CONCLUSION

From 2013 to 2017, the price of generic eye drops decreased whereas the price of branded eye drops increased. Market competition was significantly inversely associated with price changes of generic eye drops but not branded eye drops.

Characteristics of Home-Visit Nursing Agencies That Closed after the 2012 Fee Revision for Home-Visit Nursing Services: A Nationwide Panel Data Analysis in Japan

Despite the 2012 fee revision raising fees for home-visit nursing services to increase their supply in Japan, 300 to 500 home-visit nursing agencies (VNA) are still being closed annually. This study aims to identify the regional and organizational characteristics of the VNAs that closed after the 2012 fee revision. A longitudinal observational study was conducted using nationwide panel data of VNAs from 2014 to 2017 (N = 6496). Multiple logistic regression models stratified by years of operation were used for the analysis. We identified 821 closed agencies (12.6%). In this study, many important factors related to VNA closures were found. In the less than three years group, there were regional factors (lower aging rate and larger number of clinics) and an organizational factor (higher proportion of users under 40 years of age). In the 3–14 years group, there was a regional factor (larger number of clinics) and organizational factors (smaller number of FTE nurses, smaller number of users per FTE nurse, and smaller number of medical care types that can be provided). In the over 15 years group, there was an organizational factor (smaller number of FTE nurses). The findings provide valuable insights for policymakers in avoiding VNA closures.

Multifaced Evidence of Hospital Performance in Pennsylvania

As health care costs and demands for health care services have been rising for decades in the United States, health care reforms have focused on increasing the performance of health care delivery. Competition has been considered as a mechanism to improve the quality of health care services and operational performance. Evidence on health care performance and market competition, however, has not sufficiently been reported to track its progress. The purpose of this study is twofold: First, we measure hospital performance over nine years, using the Malmquist Productivity Index. Second, we examine the impact of market competition on hospital efficiency in Pennsylvania, using a two-stage estimation procedure. The bootstrapped Malmquist productivity indices resulted in noticeable performance improvements. However, no steady performance trends were found during the course of nine years. In examining the impact of market competition, the bootstrapped panel Tobit analysis was applied after computing the efficiency scores with Data Envelopment Analysis. The results of the Tobit model found that hospitals run more efficiently in less competitive regions than in more competitive regions. The finding implies that hospitals underperforming in productivity growth should benchmark best practices of efficient hospitals to improve their productivity level. Another implication is that market competition would not be the best approach to effect the improvement of hospital efficiency in delivering health care services.

Market Exclusivity of the Originator Drugs in South Korea: A Retrospective Cohort Study

Introduction: Generic entry is a well-known driver of competition and cost containment.

Objectives: We aim to measure the market exclusivity of originator drugs and to determine what influences the entry of generics in South Korea.

Methods: A list of originator drugs approved by the authority from 2000 to 2013 and their corresponding generics were paired. An event history model was applied for a statistical estimation for the duration until generic entry and to identify abbreviating or prolonging factors on the duration.

Results: A total of 2,061 pairs of originator and generics were identified. The market exclusivity for the originator drugs, including NDAs and non-NDAs, has not notably changed. However, competition among non-NDAs was less common than we expected. We found delayed time to entry of generics in the long run, particularly for non-NDAs in injection forms and biologics, and this finding is partially associated with market attractiveness.

Conclusion: The authority should address the delayed availability of certain types of generic drugs. The government could provide information on off-patent pharmaceuticals with no generic competition, designate their corresponding submissions as prioritized in the review process, and provide additional market exclusivity when entering the market via a long period of exclusivity.

Weighing the Effects of Vertical Integration Versus Market Concentration on Hospital Quality

Provider organizations are increasing in complexity, as hospitals acquire physician practices and physician organizations grow in size. At the same time, hospitals are merging with each other to improve bargaining power with insurers. We analyze 29 quality measures reported to the Center for Medicare and Medicaid Services' Hospital Compare database for 2008 to 2015 to test whether vertical integration between hospitals and physicians or increases in hospital market concentration influence patient outcomes. Vertical integration has a limited effect on a small subset of quality measures. Yet increased market concentration is strongly associated with reduced quality across all 10 patient satisfaction measures at the 95% confidence level (p < .05) and 6 of the 10 patient satisfaction measures remain statistically significant with a Bonferroni corrected p value (p < .005). Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition, and reduce counterproductive barriers to entry.

Who Joins the Franchise, Affiliation Model of Hospital Networks? An Analysis of Hospital and Market Characteristics of Members

Joining nonownership based, organization-driven networks and alliances is a common strategy for hospitals to pursue yet little is known about what types of hospitals join these collaborations, due in part to challenges in identifying members. One novel network form that has recently emerged, and made identification feasible, is franchise-like "affiliation networks" in which affiliate hospitals pay an annual membership fee that allows access to the clinical expertise and resources of high-status, nationally ranked sponsor hospitals. Affiliation networks and their members publicize affiliation. Using 2006-2015 data on United States' hospitals, we find hospitals with higher patient acuity, teaching hospitals, and hospitals located in areas of higher utilization intensity were more likely to join an affiliation network. Joining affiliation networks does not appear to be in response to highly competitive markets because hospitals in less competitive environments are more likely to join and hospitals with higher net incomes are more likely to join.

Understanding Medicare ACO Adoption in the Context of Market Factors

Medicare Accountable Care Organizations (ACOs) have achieved high-quality performance and recent cost savings, but little is known about how local market conditions influence provider adoption. The authors describe physician practice participation in Medicare ACOs at the county level and use adjusted logistic regression to assess the association between ACO presence and 3 characteristics hypothesized to influence ACO formation: physician market concentration, Medicare Advantage (MA) penetration, and commercial health insurance market concentration. Analyses are repeated on urban and rural county subgroups to examine geographic differences in ACO adoption. Practice participation in ACOs grew 19% nationally from 5.4% to 6.4% of practices between 2015 to 2017, but participation lagged in the West and rural counties, the latter of which had relatively concentrated physician markets and low MA penetration. After controlling for urban location, population density, and other covariates, ACO presence in a county was independently associated with less concentrated physician markets and moderate MA penetration but not commercial insurance concentration. The evidence suggests that Medicare ACO programs have continued appeal to physician practices, but additional engagement strategies may be needed to expand adoption in rural areas. In addition, greater practice competition and MA experience may facilitate ACO adoption. These insights into the relationship between market conditions and ACO participation have important implications for policy efforts to accelerate Medicare payment transformation.

Number of manufacturers and generic drug pricing from 2005 to 2017

OBJECTIVES

To evaluate how changes in generic drug prices and the incidence of abrupt price increases varied with the number of manufacturers supplying each drug.

STUDY DESIGN

Analysis of 2005 to 2016 monthly wholesale acquisition costs (WACs) and University of Pittsburgh Medical Center Health Plan counts of pharmacy claims for National Drug Codes (NDCs) for generic drugs.

METHODS

Each year, NDCs were categorized according to the number of manufacturers offering each combination of active ingredient and dosage form: 1 to 3, 4 to 7, and more than 7. For every month from January 2006 to January 2017, we estimated the 12-month change in WAC (eg, 12-month change in January 2006 was calculated as the difference in WAC between January 2006 and January 2005, divided by the WAC in January 2005), before and after weighting each NDC by counts of pharmacy claims. We evaluated the proportion of NDCs that had large price increases, greater than 20%, 50%, 100%, and 500% within a year.

RESULTS

Before 2010, price changes were higher for drugs supplied by a lower number of manufacturers; however, after 2010, prices increased sharply, and drugs supplied by 4 to 7 manufacturers showed increases similar to or higher than those supplied by 1 to 3. In 2013, prices increased by an average of 29% for drugs supplied by 1 to 3 and 4 to 7 manufacturers, and 10% for more than 7. Price changes increased after weighting by counts of pharmacy claims, demonstrating that price increases disproportionately affected widely used drugs. The proportion of NDCs from drugs supplied by 1 to 3 manufacturers that doubled in price within a year was 3.6 times higher in 2012 to 2015 than in 2005 to 2009 (4.6% vs 1.3%, respectively).

CONCLUSIONS

Increases in generic drug prices are concerning because they affected widely used drugs and suggest that generic drug prices may be increasingly insensitive to competition.

An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products

OBJECTIVES

Public health policies are often enacted without adequate consideration of the existing market structure or their impacts on that market structure. This paper provides context for the potential impact of regulations on nicotine vaping products (NVP) use by providing a structural analysis of competition in the US NVP market before FDA regulation.

METHODS

A literature review was conducted with the aim of providing a framework for analysis that: 1) defines the market; 2) evaluates market concentration; 3) identifies entry barriers; and 4) examines firm conduct.

RESULTS

The NVP market includes retail, internet sellers and vape shops. Although conventional retail became more concentrated after the major cigarette companies entered the NVP market, the vape shop and internet sectors remain substantially less concentrated, producing an overall low market concentration, with few entry barriers and competitive behavior.

CONCLUSIONS

The largely unregulated US NVP market has been highly competitive, with a high degree of innovation. However, new FDA deeming regulations as applied to NVPs could make it difficult for smaller companies to remain in the market and could discourage new companies and new product innovations from entering the market.

The US Cigarette Industry: An Economic and Marketing Perspective

Objectives

Tobacco company conduct has been a central concern in tobacco control. Nevertheless, the public health community has not taken full advantage of the large economics and marketing literature on market competition in the cigarette industry.

Methods

We conducted an unstructured narrative review of the economics and marketing literature using an antitrust framework that considers: 1) market; definition, 2) market concentration; 3) entry barriers; and 4) firm conduct.

Results

Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. Entry barriers have included brand proliferation, slotting allowance contracts with retailers and government regulation. While cigarette sales have declined, established firms have used coordinated price increases, predatory pricing and price discrimination to sustain their market power and profits.

Conclusions

Although the major cigarette firms have exercised market power to increase prices and profits, the market could be radically changing, with consumers more likely to use several different types of tobacco products rather than just smoking a single cigarette brand. Better understanding of the interaction between market structure and government regulation can help develop effective policies in this changing tobacco product market.

Market Consolidation and Mortality in Patients Initiating Hemodialysis

BACKGROUND

It is uncertain whether consolidation in health care markets affects the quality of care provided and health outcomes.

OBJECTIVES

To examine whether changes in market competition resulting from acquisitions by two large national for-profit dialysis chains were associated with patient mortality.

METHODS

We identified patients initiating in-center hemodialysis between 2001 and 2009 from a registry of patients with end-stage renal disease in the United States. We considered two scenarios when evaluating consolidation from dialysis facility acquisitions: one in which we considered only those patients receiving dialysis in markets that became substantially more concentrated to have been affected by consolidation, and the other in which all patients living in hospital service areas where a facility was acquired were potentially affected. We used a difference-in-differences study design to examine the associations between market consolidation and changes in mortality rates.

RESULTS

When we considered the 12,065 patients living in areas that became substantially more consolidated to have been affected by consolidation, we found a nominally significant (8%; 95% confidence interval 0%-17%) increase in likelihood of death after consolidation. Nevertheless, when we considered all 186,158 patients living in areas where an acquisition occurred to have been affected by consolidation, there was no observable effect of market consolidation on mortality.

CONCLUSIONS

Decreased market competition may have led to increased mortality among a relatively small subset of patients initiating in-center hemodialysis in areas that became substantially more concentrated after two large dialysis acquisitions, but not for most of the patients living in affected areas.

How did market competition affect outpatient utilization under the diagnosis-related group-based payment system?

Objective

Although competition is known to affect quality of care, less is known about the effects of competition on outpatient health service utilization under the diagnosis-related group payment system. This study aimed to evaluate these effects and assess differences before and after hospitalization in South Korea.

Design

Population-based retrospective observational study.

Setting

We used two data set including outpatient data and hospitalization data from National Health Claim data from 2011 to 2014.

Participants

Participants who were admitted to the hospital for hemorrhoidectomy were included. A total of 804 884 hospitalizations were included in our analysis.

Main outcome measure(s)

The outcome variables included the costs associated with outpatient examinations and the number of outpatient visits within 30 days before and after hospitalization.

Results

High-competition areas were associated with lower pre-surgery examination costs (rate ratio [RR]: 0.88, 95% confidence interval [CI]: 0.88-0.89) and fewer outpatient visits before hospitalization (RR: 0.98, 95% CI: 0.98-0.99) as well as after hospitalization compared with moderate-competition areas.

Conclusion

Our study reveals that outpatient health service utilization is affected by the degree of market competition. Future evaluations of hospital performance should consider external factors such as market structure and hospital location.

The association of market competition with hospital charges, length of stay, and quality outcomes for patients with joint diseases: a longitudinal study in Korea

This study investigated the association of market competition with hospital charges, length of stay, and quality outcomes. A total of 279,847 patients from 851 hospitals were analyzed. The Herfindahl-Hirschman Index was used as a measure of hospital market competition level. Our results suggest that hospitals in less competitive markets charged more on charge per admission, possibly by increasing the length of stays, however, hospitals in more competitive markets charged more for daily services by providing more intensive services while reducing the length of stays, thereby reducing the overall charge per admission. Quality outcomes measured by mortality within 30 days of admission and readmission within 30 days of discharge were better for surgical procedures within competitive areas. Continued government monitoring of hospital response to market competition level is recommended in order to determine whether changes in hospitals' strategies influence the long-term outcomes of services performance and health care spending.

International experiences of promoting generics use and its implications to China

OBJECTIVE

To summarize international experiences in promoting use of generics and to extract essence for China's reference.

METHOD

This is a commentary of two systematic reviews about policies to promote use of generics and its implications to China.

RESULT

Price, reimbursement, and generic substitution policies in European countries, and approaches in low and middle income countries in promoting market competition, appropriate intellectual property right protection strategy, and necessary demand side incentives, are all meaningful for China to contain soaring pharmaceutical expenditures, and to maintain the achievements and outcomes of the national health system reform.

CONCLUSION

Effective promotion of generics use must be practice based on the real situation. Tailor-made and comprehensive measures are needed to address both demand and supply sides barriers before achieving tangible cost containment effect without unexpected side effects.