Special Report
The Marketplace in Health Care Reform -- The Demographic Limitations of Managed Competition
N Engl J Med 1993; 328:148-152January 14, 1993
- Abstract
Background
The theory of managed competition holds that the quality and economy of health care delivery will improve if independent provider groups compete for consumers. In sparsely populated areas where relatively few providers are required, however, it is not feasible to divide the provider community into competing groups. We examined the demographic features of health markets in the United States to see what proportion of the population lives in areas that might successfully support managed competition.
Methods
The ratios of physicians to enrollees in large staff-model health maintenance organizations were determined as an indicator of the staffing needs of an efficient health plan. These ratios were used to estimate the populations necessary to support health organizations with various ranges of specialty services. Metropolitan areas with populations large enough to support managed competition were identified.
Results
We estimated that a health care services market with a population of 1.2 million could support three fully independent plans. A population of 360,000 could support three plans that independently provided most acute care hospital services, but the plans would need to share hospital facilities and contract for tertiary services. A population of 180,000 could support three plans that provided primary care and many basic specialty services but that shared inpatient cardiology and urology services. Health markets with populations greater than 180,000 would include 71 percent of the U.S. population; those with populations greater than 360,000, 63 percent; and those with populations greater than 1.2 million, 42 percent.
Conclusions
Reform of the U.S. health care system through expansion of managed competition is feasible in medium-sized or large metropolitan areas. Smaller metropolitan areas and rural areas would require alternative forms of organization and regulation of health care providers to improve quality and economy.
Media in This Article
Figure 1
Health Markets with Populations ≥ 360,000 in the United States.Table 1
Estimated Number of Full-Time-Equivalent Physicians and Hospital Beds Needed, According to the Size of the Health Plan.Article Activity
- Article
Managed competition has received widespread support from members of Congress, President-elect Bill Clinton, large insurance companies, and editorialists writing in influential publications1-4. A central tenet of the managed-competition theory is that providers are divided into competing economic units. As discussed by Enthoven and Kronick,5,6 the most effective competition occurs when all the doctors in a community are grouped into several prepaid practices with each doctor fully committed to one organization. Health care services, however, are largely purchased locally, and there are sparsely populated areas of the United States where providers have a natural monopoly. In a geographically isolated area with a population base large enough to support only one hospital and one group of physicians, it is difficult to envision how competition would work. If the hospital decides to increase its scope of services or its prices substantially, threatening to build a competing hospital is a poor option, and transporting patients to another city may be unacceptable. Similarly, if most physicians are members of a single multispecialty group practice, purchasers have little recourse if the physicians use more, rather than fewer, resources.
We estimated the minimal population size for a health services market area that could support managed competition and the proportion of the population of each state and of the nation as a whole that is in such areas.
Methods
An estimate of the minimal population required to support managed competition is based on four assumptions: the extent to which competing health care organizations need to be independent; the minimal number of health care organizations needed to support healthy competition; the ratios of physicians to enrollees and of hospital beds to enrollees in efficiently managed health plans; and the geographic boundaries of health services markets. This section presents the assumptions and methods we used to make our estimates.
To What Extent Must Competing Organizations Be Independent?
The “classic” health maintenance organization (HMO) -- the large, staff-model prepaid group practice epitomized by Kaiser-Permanente or Group Health Cooperative of Puget Sound -- is the prototype of the efficient competitor. Unlike many other forms of managed care, classic HMOs are capable of health planning: they regulate the supply of hospital beds, physicians, and other providers in relation to the size of the population they serve. Physicians employed by classic HMOs, because they are salaried, are not subject to the tendencies toward supplier-induced demand inherent in fee-for-service medicine; they are able to allocate their workloads efficiently among various tasks, such as evaluating and counseling patients, performing operations or diagnostic tests, and performing the duties required for continuous improvement in the quality of care. This flexibility makes it possible for classic HMOs to adapt easily to the changes in demand that occur when patients are informed about medical options and make decisions according to their preferences7.
The efficiency of the classic HMO model contrasts sharply with that of the independent practice association (IPA) model, particularly when individual physicians are affiliated with many health plans. Enthoven describes the inefficiencies of an IPA market in which each physician belongs to 10 plans:
Each doctor would have to deal with the utilization controls and fee schedules of ten health plans, none of which would command his loyalty. If one health plan persuaded a doctor to adopt a more efficient health practice, the benefit would be likely to be spread immediately over all ten plans, reducing the incentive of any plan to make the effort to pursue innovation at the provider level. None of the health plans would be matching numbers of doctors to the needs of the population6.
Between the contrasting extremes of the mature classic HMO and the multiple-IPA model is a large, ambiguous middle ground. Each of a set of health plans might have its own primary care physicians and contract with the same specialists. Or, in addition to primary care, a plan might provide some specialty services (such as cardiology, urology, and gastroenterology), using its own physicians during regular business hours, but it might contract with overlapping sets of providers for after-hours specialty care and for inpatient services. When considering competition among health plans that are less comprehensive than classic HMOs, a key factor is the configuration of inpatient hospital services in a community. If health plans are not large enough to own their own hospitals and hire the full complement of specialists but, instead, contract separately with overlapping sets of hospitals, then no organization will be responsible and accountable for population-based health planning for hospital services.
In areas in which the population is too small to allow competing health plans to exert effective control over specialists' services and hospital resources, some alternative or adjunct to managed competition will be required in order to achieve effective health planning. Conceivably, this might be accomplished by cooperative planning efforts by the major health plans operating in a community. Alternatively, some form of government regulation of hospital capacity and budgets may be necessary.
How Many Competitors Are Needed?
Ideally, a large number of qualified health care plans would be available in each geographic area. No single plan would be able to have much influence on the demand for care, thus making collusion among plans difficult. However, the minimal number of plans needed to avoid a market with strong oligopolistic tendencies is not clear. One competitor is obviously not enough. If there are only two competitors, the temptation of implicit collusion will be hard to resist. Why should the competitors work hard to restrain the growth of costs or profits when both competitors will be better off if they engage in cozy behavior? There is no theoretical basis on which to infer the minimal number of firms that can successfully sustain competition, but the fewer there are, the greater the tendency toward oligopoly. Somewhat arbitrarily, we assumed that at least three health plans are needed in order to create a situation in which providers and plans will continually strive to improve quality and economy.
What Is the Critical Population Size Needed to Sustain an Efficient Firm?
The size of the population required for a managed-care firm to organize efficient primary care and specialty units varies according to specialty and according to assumptions about the minimal number of physicians needed to sustain the service. We grouped physician specialties into four categories. The first, primary care, included general internal medicine, pediatrics, and family medicine. For these specialties we assumed that at least five physicians are needed to provide full night coverage and to sustain the collegial relations required for high-quality care in the group-practice environment.
The second category included hospital-based specialties that involve frequent night and weekend consultation for emergencies or postoperative care and that are required in a full-service acute care community hospital -- specifically, emergency medicine, obstetrics and gynecology, general surgery, orthopedics, anesthesiology, radiology, psychiatry, cardiology, and urology. For these specialties, we assumed that three full-time physicians are needed to staff a minimal service in order to meet coverage obligations and provide high-quality care. We used these specialties to estimate the lower limit of the zones where competition based on the classic HMO model might succeed if there were some sharing of hospital facilities, with staffs independent.
The third category included neurosurgery and cardiothoracic surgery, the additional three-physician specialty services required for a tertiary hospital. This sets the minimum for a classic HMO that is fully independent for all clinical specialties. The fourth category consisted of other specialties involving secondary and tertiary care that is usually not of an emergency nature -- ophthalmology, otolaryngology, dermatology, pathology, hematology and oncology, neurology, gastroenterology, allergy and immunology, pulmonary medicine, nephrology, rheumatology, endocrinology, infectious diseases, and plastic and reconstructive surgery. On the basis of our estimate that 24-hour coverage is not essential for these specialties, we assumed that the services of only one specialist are required to achieve independence.
To estimate the population required for independence and efficiency, we examined the staffing patterns of the Group Health Cooperative of Puget Sound and four other large, nonprofit staff-model HMOs. For each classic HMO, data were provided by the organization's medical staff office. For most specialties the number of enrollees per specialist was averaged across plans to derive an estimate for the HMOs as a whole. To estimate the need for primary care practitioners we used the Group Health Cooperative's staffing ratio for family practitioners (1 to 2000). For emergency medicine, psychiatry, pathology, and thoracic surgery, we used data from other sources8,9. (Supplemental material on our procedures is available elsewhere.NAPS)
The age structure of the enrollees was obtained for the age groups ≤ 14, 15 through 44, 45 through 64, and ≥ 65 years. The proportion of enrollees in each age group approximated the national age distribution except for the population 65 years of age or older. The elderly make up 12.5 percent of the national population, whereas the percentages for the five HMOs were 11.7, 9.4, 8.0, 11.4, and 8.2 percent.
HMOs typically use fewer than 2 beds per 1000 enrollees. The estimate of 2 beds per 1000 is compatible with the assumptions that the population under 65 years of age uses 350 hospital days per year per 1000 enrollees and the population 65 or older uses 2430 days per 1000; that 13 percent of the enrollees are 65 or older; and that hospital occupancy is 85 percent.
What Are the Location and Size of Health Care Markets?
We assumed that metropolitan areas, as defined by the Office of Management and Budget,10 are the relevant market areas for health services in nonrural parts of the United States. Metropolitan areas are defined as a “place” with a population of at least 50,000 or an “urbanized area,” as defined by the U.S. Bureau of the Census, with a population of 50,000 and a metropolitan area with a total population of at least 100,000. Surrounding counties are included if they have a minimal commuting rate to the central county. This definition of metropolitan areas results in high-density geographic units with economic and travel ties that are consistent with a regional economic market11,12. The size and location of health services markets for people living outside metropolitan areas are usually determined on the basis of small-area analysis. Although we were not able to perform such an analysis for the entire nation, previous studies in northern New England have resulted in the division of this territory into 72 distinct hospital market areas13. We used these areas to illustrate the constraints of demographic forces on managed care in nonmetropolitan areas.
Results
Population Requirements for Managed-Care Organizations
The minimal population necessary to support a classic HMO offering referral hospital services and using its own staff physicians is approximately 450,000 enrollees. A health plan with 300,000 enrollees would be able to offer virtually all ambulatory and hospital services with its own panel of providers and own a 600-bed hospital, but it would need to contract for some coverage of cardiothoracic surgery and neurosurgery. A plan with 120,000 enrollees could provide the full complement of acute care hospital services associated with a community hospital, using its own staff physicians, although the cardiology and urology services would be close to the minimal three-person service. This plan would need approximately 240 hospital beds; it would be able to exert substantial control over one or two hospitals, but it would have to share some inpatient facilities with other plans. A plan with 60,000 enrollees could support 71 full-time-equivalent physicians (Table 1Table 1
Estimated Number of Full-Time-Equivalent Physicians and Hospital Beds Needed, According to the Size of the Health Plan.) and a 3-physician service in most of the specialties required for general hospital services, but it would need to share cardiology and urology services and engage in substantial sharing of inpatient facilities with other plans. A plan with 10,000 members could support an independent primary care service but would be required to share both physicians and inpatient hospital services in all specialties.Population Required for Managed Competition
Assuming that three health plans are the minimum required for competition, then at least 360,000 persons are needed to support three HMOs that can plan for and deliver most general hospital services, although sharing of acute care hospital facilities would be necessary. A smaller community of 180,000 could support three health plans capable of providing a large portion of physicians' services in hospitals, using physicians who are employed as staff by the health plan, but they would require shared inpatient services. A community of 30,000 might support three independent primary care networks, but all hospital services would need to be shared if the residents were to receive inpatient care locally. At the other extreme, a much larger community of at least 1.2 million persons would be required to support three HMOs capable of providing almost all services with their own resources.
Proportion of the U.S. Population Living in Competitive Zones
Twenty-nine percent of the U.S. population lives in markets with populations below 180,000 and thus in areas where substantial sharing of hospital services would be required for use to be efficient (Table 2Table 2
Percentage of State (or District) Populations in Different-Sized Health Market Areas.). Eight percent live in markets with populations between 180,000 and 360,000, where managed competition has some potential to organize acute hospital care at least semi-independently, but where plans would need to be supplemented with substantial public-sector involvement in health planning. Twenty-one percent are in markets with populations between 360,000 and 1.2 million, where the demographic requirements for HMO-based managed competition are largely met but where some public-sector efforts are likely to be required in the planning of tertiary hospital services. Forty-two percent reside in markets with populations of more than 1.2 million.The location of these markets in the United States is shown in Figure 1Figure 1
Health Markets with Populations ≥ 360,000 in the United States.. Twenty-three states and the District of Columbia have at least one metropolitan area with a population of 1.2 million or more, sufficient to support three classic HMOs, each owning a referral hospital; in 10 (Arizona, California, the District of Columbia, Illinois, Maryland, Minnesota, Missouri, New Jersey, New York, and Texas) the majority of the people live in such areas. However, large land areas in the United States are outside the competitive zone for HMOs, and no state is entirely within it. Most states will require mixed strategies. Some part of their populations live in areas where managed competition could be effective in promoting HMOs, but many live in more sparsely settled areas where other strategies are needed. In 19 states the majority of the population lives in areas of less than 180,000 population, where hospital services must be extensively shared. In 42 states, 20 percent or more of the population lives in such areas.The health markets in northern New England illustrate the complexities of structuring competition in states with no large metropolitan areas. Maine, New Hampshire, and Vermont together contain 83 acute care general hospitals and 2.5 million people; 64 of the hospitals are the sole hospitals in their local areas. The vast majority of primary care services in these areas are delivered by local physicians who use the local hospital for their patients. None of these areas have a big enough population to support three independent cardiology services. Only two market areas -- Portland, Maine, and Manchester, New Hampshire (containing 13 percent of the population) -- are sufficiently large to support three independent general-surgery, emergency, and orthopedic services. Twenty-seven percent of the population of northern New England lives in hospital market areas that cannot support three independent primary care competitors, assuming that each plan would need to have at least five physicians.
Discussion
We recognize several limitations to our study that cause uncertainty about our estimates. We estimated the minimal population required to support three efficient organizations in a steady state; population estimates may be unrealistic, however, since the motivation of competition includes growth and in small markets this cannot occur without driving a competitor out of business. Our assumption that three competitors are sufficient to avoid collusion cannot be supported by empirical evidence, since managed competition is an experiment that has yet to run its course. Three may not be enough. Each of these factors would tend to cause us to underestimate the market size required to promote efficient competition. We have also not considered other potential limits to reform, such as barriers to enrollment of providers and bureaucratic inefficiencies in the case of public-sector health planning. On the other hand, since the enrollees of HMOs tend to be younger than the general population, smaller health markets could support managed competition with a higher proportion of elderly persons. The conclusion, however, is the same: demographic factors will limit the full implementation of managed competition as the vehicle for reforming the U.S. health care economy.
We hope our study will help to move the policy debate beyond polarization, either for or against competition and regulation. The complexities and the highly localized nature of the health care economies in the various states indicate the need for care on the part of state governments in setting the rules for structured competition, or the need for alternative models of reform (based on planning and the promotion of cooperation as the basis for achieving the efficiencies that the population-based perspective of the classic HMO brings to the health care economy). Monitoring by the states should be based on a sophisticated understanding of their health care systems, including detailed information about the location and level of use of resources in local and regional markets. Each state will need to recognize the limitations as well as the advantages of managed competition, particularly the need for support within an overall regulatory framework that can deal effectively with all the territory within its jurisdiction.
We recommend that the states be given wide latitude to undertake experiments in setting the rules for managing health care reform within their territory. We expect a provocative series of experiments that promote a variety of approaches to the complex problem of building population-based systems of care. Some will result in as yet unanticipated hybrid solutions that reflect demographic factors, the history of the state's health care industry, and regional traditions and preferences.
Supported by a grant (HS 05745-05) from the Agency for Health Care Policy and Research.
NAPS See NAPS document no. 04998 for two pages of supplementary material. To order, contact NAPS c/o Microfiche Publications, 248 Hempstead Tpk., West Hempstead, NY 11552.
We are indebted to Chiang-Hua Chang, M.S., and Thomas Bubolz, Ph.D., for their analytic support.
Source Information
Address reprint requests to Dr. Kronick at the Department of Community and Family Medicine, University of California-San Diego, La Jolla, CA 92093.
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