Hospital cost and quality performance in relation to market forces: an examination of U.S. community hospitals in the “post-managed care era”



Managed care substantially transformed the U.S. healthcare sector in the last two decades of the twentieth century, injecting price competition among hospitals for the first time in history. However, total HMO enrollment has declined since 2000. This study addresses whether managed care and hospital competition continued to show positive effects on hospital cost and quality performance in the “post-managed care era.” Using data for 1,521 urban hospitals drawn from the Healthcare Cost and Utilization Project, we examined hospital cost per stay and mortality rate in relation to HMO penetration and hospital competition between 2001 and 2005, controlling for patient, hospital, and other market characteristics. Regression analyses were employed to examine both cross-sectional and longitudinal variation in hospital performance. We found that in markets with high HMO penetration, increase in hospital competition over time was associated with decrease in mortality but no change in cost. In markets without high HMO penetration, increase in hospital competition was associated with increase in cost but no change in mortality. Overall, hospitals in high HMO penetration markets consistently showed lower average costs, and hospitals in markets with high hospital competition consistently showed lower mortality rates. Hospitals in markets with high HMO penetration also showed lower mortality rates in 2005 with no such difference found in 2001. Our findings suggest that while managed care may have lost its strength in slowing hospital cost growth, differences in average hospital cost associated with different levels of HMO penetration across markets still persist. Furthermore, these health plans appear to put quality of care on a higher priority than before.


Managed care Hospital cost Mortality rates Hospital competition 

JEL Classification



  1. Agency for Healthcare Research and Quality. (2001). Refinement of the HCUP quality indicators. Rockville, MD: AHRQ.Google Scholar
  2. Agency for Healthcare Research and Quality. (2006). Quality indicators risk adjustment and hierarchical modeling draft report. Rockville, MD: AHRQ.Google Scholar
  3. Agency for Healthcare Research and Quality. (2007). Inpatient quality indicators (version 3.1, March 2007). Rockville, MD: AHRQ.Google Scholar
  4. Bamezai, A., Zwanziger, J., Melnick, G. A., & Mann, J. M. (1999). Price competition and hospital cost growth in the United States (1989–1994). Health Economics, 8, 233–243.PubMedCrossRefGoogle Scholar
  5. Blough, D. K., Madden, C. W., & Hornbrook, M. C. (1999). Modeling risk using generalized linear models. Journal of Health Economics, 18, 153–171.PubMedCrossRefGoogle Scholar
  6. Cutler, D. M. (1995). The incidence of adverse medical outcomes under prospective payment. Econometrics, 63(1), 29–50.CrossRefGoogle Scholar
  7. Drake, D. F. (1997). Managed care: A product of market dynamics. Journal of the American Medical Association, 277, 560–563.PubMedCrossRefGoogle Scholar
  8. Devers, K. J., Brewster, L. R., & Casalina, L. P. (2003). Changes in hospital competitive strategy: A new medical arms race? Health Services Research, 38(1 Pt 2), 447–469.PubMedCrossRefGoogle Scholar
  9. Devers, K. J., Casalino, L. P., Rudell, L. S., Stoddard, J. J., Brewster, L. R., & Lake, T. K. (2003). Hospitals’ negotiating leverage with health plans: How and why has it changed? Health Services Research, 38(1 Pt 2), 419–446.PubMedCrossRefGoogle Scholar
  10. Dranove, D., & Cone, K. (1985). Do state rate setting regulations really lower hospital expenses? Journal of Health Economics, 4(2), 159–165.PubMedCrossRefGoogle Scholar
  11. Escarce, J. J., Jain, A. K., & Rogowski, J. (2006). Hospital competition, managed care, and mortality after hospitalization for medical conditions: Evidence from three states. Medical Care Research and Review, 63, 112S–140S.PubMedCrossRefGoogle Scholar
  12. Gaskin, D. J., Escarce, J. J., Schulman, K., & Hadley, J. (2002). The determinants of HMOs’ contracting with hospitals for bypass surgery. Health Services Research, 37, 963–984.PubMedCrossRefGoogle Scholar
  13. Gaskin, D. J., & Hadley, J. (1997). The impact of HMO penetration on the rate of hospital cost inflation, 1985–1993. Inquiry, 34, 205–216.PubMedGoogle Scholar
  14. Ginsburg, P. B. (2005). Competition in health care: Its evolution over the past decade. Health Affairs, 24, 1512–1522.PubMedCrossRefGoogle Scholar
  15. Gozvrisankaran, G., & Town, R. J. (2003). Competition, payers, and hospital quality. Health Services Research, 38(6 Part 1), 1403–1421.Google Scholar
  16. Hall, W. B., Willis, L. E., Medvedev, S., & Carson, S. S. (2012). The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay. American Journal of Respiratory and Critical Care Medicine, 185(1), 53–57.PubMedCrossRefGoogle Scholar
  17. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.Google Scholar
  18. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.Google Scholar
  19. Kessler, D., & McClellan, M. (2000). Is hospital competition socially wasteful? The Quarterly Journal of Economics, 115, 577–615.CrossRefGoogle Scholar
  20. Konetzka, R. T., Zhu, J., Sochalski, J., & Volpp, K. G. (2008). Managed care and hospital cost containment. Inquiry, 45(1), 98–111.PubMedCrossRefGoogle Scholar
  21. Lesser, C. S., Ginsburg, P. B., & Devers, K. J. (2003). The end of an era: What became of the “Managed Care Revolution” in 2001? Health Services Research, 38(1, Part II), 337–355.Google Scholar
  22. Manning, W. G. (1998). The logged dependent variable, heteroskedasticity, and the retransformation problem. Journal of Health Economics, 17, 283–295.PubMedCrossRefGoogle Scholar
  23. Manning, W. G., & Mullahy, J. (2001). Estimating log models: To transform or not to transform? Journal of Health Economics, 20, 461–494.PubMedCrossRefGoogle Scholar
  24. Mukamel, D. B., Zwanziger, J., & Tomaszewski, K. J. (2001). HMO penetration, competition, and risk-adjusted hospital mortality. Health Services Research, 36(6 Part 1), 1019–1035.Google Scholar
  25. Mutter, R. L., Wong, H. S., & Goldfarb, M. G. (2008). The effects of hospital competition on inpatient quality of care. Inquiry, 45(3), 263–279.PubMedCrossRefGoogle Scholar
  26. Rainwater, J. A., & Romano, P. S. (2003). What data do California HMOs use to select hospitals for contracting? American Journal of Managed Care, 9, 553–561.PubMedGoogle Scholar
  27. Robinson, J. C. (1996). Decline in hospital utilization and cost inflation under managed care in California. Journal of the American Medical Association, 276, 1060–1064.PubMedCrossRefGoogle Scholar
  28. Robinson, J. C. (2001). The end of managed care. Journal of the American Medical Association, 285(20), 2622–2628.PubMedCrossRefGoogle Scholar
  29. Robinson, J. C., & Luft, H. S. (1987). Competition and the cost of hospital care, 1972 to 1982. Journal of the American Medical Association, 257(23), 3241–3245.PubMedCrossRefGoogle Scholar
  30. Romano, P. S., & Chan, B. K. (2000). Risk-adjusting acute myocardial infarction mortality: Are APR-DRGs the right tool? Health Services Research, 34, 1469–1489.PubMedGoogle Scholar
  31. Sari, N. (2002). Do competition and managed care improve quality? Health Economics, 11, 571–584.PubMedCrossRefGoogle Scholar
  32. Schulman, K. A., Rubenstein, L. E., Seils, D. M., Harris, M., Hadley, J., & Escarce, J. J. (1997). Quality assessment in contracting for tertiary care services by HMOs: A case study of three markets. The Joint Commission Journal on Quality Improvement, 23(2), 117–127.PubMedGoogle Scholar
  33. Sun, Y., & Friedman, B. (2012). Tools for more accurate inpatient cost estimates with HCUP databases, 2009. (Errata added October 25, 2012.) HCUP Methods Series Report #. U.S. Agency for Healthcare Research and Quality.
  34. Trinh, H. Q., Begun, J. W., & Luke, R. D. (2008). Hospital service duplication: Evidence on the medical arms race. Health Care Manage Review, 33(3), 192–202.CrossRefGoogle Scholar
  35. Volpp, K. G., Ketcham, J. D., Epstein, A. J., & Williams, S. V. (2005). The effects of price competition and reduced subsidies for uncompensated care on hospital mortality. Health Services Research, 40(4), 1056–1077.PubMedCrossRefGoogle Scholar
  36. Wong, H. S., Zhan, C., & Mutter, R. (2005). Do different measures of hospital competition matter in empirical investigations of hospital behavior? Review of Industrial Organization, 26, 61–87.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2013

Authors and Affiliations

  • H. Joanna Jiang
    • 1
  • Bernard Friedman
    • 1
  • Shenyi Jiang
    • 2
  1. 1.Center for Delivery, Organization and MarketsAgency for Healthcare Research and QualityRockvilleUSA
  2. 2.Hanqing Advanced Institute of Economics and FinanceRenmin University of ChinaBeijingPeople’s Republic of China

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