How Does Competition Impact the Quality of Health Care? A Case Study of the U.S. Dialysis Industry

We examine whether and to what extent consolidation in the largely for-profit U.S. dialysis industry has affected patient outcomes and clinical practices. We make use of detailed facility data for the period 2000-2009, during which the market share of the two industry leaders increased from just over one-third to nearly two-thirds. We exploit the differential impact of two large national acquisitions on local market concentration to estimate the causal effect of concentration on a broad set of measures, including mortality rates, dialysis adequacy, and staffing ratios. We find no statistically or economically significant effects of competition on any measure. Preliminary analysis suggests consolidation may have led to higher prices for privately-insured patients.

[1]  David Dranove,et al.  Competition in health care markets. , 2014, Health affairs.

[2]  P. Kerr,et al.  Longer dialysis session length is associated with better intermediate outcomes and survival among patients on in-center three times per week hemodialysis: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). , 2012, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[3]  Stephen Gibbons,et al.  Does Hospital Competition Save Lives? Evidence from the English NHS Patient Choice Reforms , 2011, Economic journal.

[4]  M. Thamer,et al.  The effect of dialysis chains on mortality among patients receiving hemodialysis. , 2011, Health services research.

[5]  J. Wheeler,et al.  Do Resource Utilization and Clinical Measures Still Vary Across Dialysis Chains After Controlling for the Local Practices of Facilities and Physicians? , 2010, Medical care.

[6]  C. Propper,et al.  Death by Market Power: Reform, Competition and Patient Outcomes in the National Health Service , 2010 .

[7]  F. Port,et al.  International hemodialysis patient outcomes comparisons revisited: the role of practice patterns and other factors. , 2009, Clinical journal of the American Society of Nephrology : CJASN.

[8]  R. Wolfe,et al.  Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. , 2009, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[9]  David Dranove,et al.  Start spreading the news: a structural estimate of the effects of New York hospital report cards. , 2008, Journal of health economics.

[10]  J. Wheeler,et al.  Provider monitoring and pay-for-performance when multiple providers affect outcomes: An application to renal dialysis. , 2009, Health services research.

[11]  M. Pauly,et al.  End-stage renal disease and economic incentives: the International Study of Health Care Organization and Financing (ISHCOF) , 2007, International Journal of Health Care Finance and Economics.

[12]  Yi Zhang,et al.  Dialysis facility ownership and epoetin dosing in patients receiving hemodialysis. , 2007, JAMA.

[13]  Martin Gaynor,et al.  Competition and Quality in Health Care Markets , 2007, Found. Trends Microeconomics.

[14]  J. Pendergast,et al.  Effect of dialysis center profit-status on patient survival: a comparison of risk-adjustment and instrumental variable approaches. , 2006, Health services research.

[15]  F. Port,et al.  International differences in dialysis mortality reflect background general population atherosclerotic cardiovascular mortality. , 2006, Journal of the American Society of Nephrology : JASN.

[16]  J. Kaufman,et al.  Factors influencing route of administration for epoetin treatment among hemodialysis patients in the United States. , 2006, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[17]  Claudia H. Williams,et al.  How has hospital consolidation affected the price and quality of hospital care ? , 2006 .

[18]  Daniel P. Kessler,et al.  The Effects of Competition on Variation in the Quality and Cost of Medical Care , 2005 .

[19]  N. Levin,et al.  Mortality among hemodialysis patients in Europe, Japan, and the United States: case-mix effects. , 2004, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[20]  Simon Burgess,et al.  Does competition between hospitals improve the quality of care?: Hospital death rates and the NHS internal market , 2004 .

[21]  Abigail Tay,et al.  Assessing competition in hospital care markets: the importance of accounting for quality differentiation. , 2003, The Rand journal of economics.

[22]  R. Wolfe,et al.  Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: the Dialysis Outcomes and Practice Patterns Study (DOPPS). , 2003, Journal of the American Society of Nephrology : JASN.

[23]  C. Propper,et al.  Competition and Quality: Evidence from the NHS Internal Market 1991-1999 , 2003 .

[24]  Michael J. Mazzeo.  Competition and Service Quality in the U.S. Airline Industry , 2003 .

[25]  Gordon H Guyatt,et al.  Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis. , 2002, JAMA.

[26]  B H Hamilton,et al.  Hospital mergers and acquisitions: does market consolidation harm patients? , 2000, Journal of health economics.

[27]  M Diener-West,et al.  Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation. , 1999, The New England journal of medicine.

[28]  R. Wolfe,et al.  Trends in treatment and survival for hemodialysis patients in the United States. , 1998, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[29]  D. Farley.  Competition under Fixed Prices: Effects on Patient Selection and Service Strategies by Hemodialysis Providers , 1996, Medical care research and review : MCRR.

[30]  C. Hoxby,et al.  Appendices to : “ Does Competition among Public Schools Benefit Students and Taxpayers ? , 2004 .

[31]  David Dranove,et al.  Recent Theory and Evidence on Competition in Hospital Markets , 1994 .

[32]  Avrom Sherr,et al.  The impact of competition on pricing and quality of legal services , 1989 .

[33]  M. Pauly,et al.  Competition and efficiency in the end stage renal disease program. , 1983, Journal of health economics.

[34]  H. Demsetz.  Industry Structure, Market Rivalry, and Public Policy , 1973, The Journal of Law and Economics.

[35]  David Dranove,et al.  Health Care Markets, Regulators, and Certifiers , 2011 .

[36]  S. Ramanarayanan.  Reputations and Firm Performance: Evidence from the Dialysis Industry , 2011 .

[37]  Min Chen.  Competition, quality choices and vertical differentiation: Applications to the nursing home industry , 2008 .

[38]  R. Town,et al.  The welfare impact of Medicare HMOs. , 2003, The Rand journal of economics.

[39]  R. Hirth,et al.  Ownership, competition, and the adoption of new technologies and cost-saving practices in a fixed-price environment. , 2000, Inquiry : a journal of medical care organization, provision and financing.

[40]  A. Nissenson,et al.  Medicare's end-stage renal disease program: current status and future prospects. , 1999, Health affairs.

[41]  R. Brook,et al.  Competition and quality. , 1988, Health affairs.