Antitrust in the Labor Market: Protectionist, or Pro-Competitive?

https://promarket.org/antitrust-labor-market-protectionist-pro-competitive/

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Redirecting antitrust enforcement to confront monopsony power would be a substantial departure from the way it has been conducted in recent decades, but just because a policy has been in place for a long time does not mean it is a success, and recent evidence implies a significant policy change is necessary and justified.

The very first sentence of the United States submission to the OECD’s “Global Forum on Competition” in 2015 reads “The U.S. Federal Trade Commission and the Antitrust Division of the Department of Justice do not consider employment or other non-competition factors in their antitrust analysis.”

Employment isn’t a “competition factor?” A growing body of evidence, drawn from both micro and macro sources, implies that the labor market has been slack since the Great Recession thanks to an aggregate demand shortfall. The employment-to-population ratio, labor force participation, job-to-job and geographic mobility, and the job ladder as a whole have all stagnated for almost a decade, and even before 2008 these indicators had barely made up ground since the recession of the early 2000s. Wages have been stagnant, and thus the labor share of national income has been in decline.

Over an even longer period, worker compensation has failed to keep pace with productivity gains per capita. The broadening literature on the rise of earnings inequality between firms, controlling for worker characteristics, implies that workers do not receive sufficient job offers to equalize the earnings they receive across firms. All of these phenomena are explained by rising monopsony power in the labor market.

The recent paper by De Loecker and Eeckhout makes this point explicit: the ability of employers to extract rents in the labor market causes a reduction in the market demand for labor, and this in turn motivates all of the manifestations of a slack labor market just described, as well as the rising markups that are the central finding of that paper. Profits have risen, reflecting rising market power in both labor and product markets—a finding that is consistent with the aggregate analysis done by Barkai.

So if monopsony power constrains employment, why not consider it a factor in antitrust analysis? After all, the premise of economic analysis in antitrust is that market power threatens welfare by restricting output and raising prices. Why doesn’t market power threaten welfare by reducing demand for labor and lowering wages?

Existing antitrust policy treats maximizing consumer welfare as the ultimate end goal of antitrust policy, and that policy aim makes sense in a world of little market power, where profits are low and the economy is assumed to be on its production possibility frontier. In that world, maximizing consumer welfare is a suitable summary statistic for overall wellbeing.

Moreover, since the revolution in antitrust policy associated with Robert Bork put such an emphasis on sustaining an “economies” defense—meaning that potentially efficiency-enhancing aspects of corporate mergers and conduct must be weighed against inefficiencies arising from market power—the potential for monopsony power has been considered a plus. After all, enforcers and courts generally assumed that any gains at the expense of workers would be passed to consumers in the form of lower prices, since product markets would be competitive (and if not, the potential for entry would exert a disciplining influence). In that world, caring about employment, wages, or other labor market outcomes looks like protectionism, impeding the competitive pressure that yields the best outcomes for consumers, and favoring certain privileged “insider” workers at the expense of others.

We know now that we don’t live in that world, and that revelation calls for a wholesale re-think of the proper goals of antitrust policy, very much including whether the sole focus on consumer welfare makes sense when powerful corporations squeeze workers and then pocket the gains for themselves and their shareholders.

What would it actually look like to bring antitrust into the labor market?

As with any enforcement regime, antitrust often starts with the lowest-hanging fruit: out-and-out written evidence of anti-competitive practices, such as the Justice Department’s 2010 lawsuit against Silicon Valley employers for colluding not to hire one another’s programmers. This is partly why the recent increase in the use of non-compete clauses has drawn attention in antitrust circles. As a would-be vertical restraint, non-compete clauses aren’t as easy to target under antitrust as horizontal collusion, but they are there, in writing—prohibitions on competition in the labor market, to the benefit of employers. And they should be banned, or at the very least subjected to a high burden of proof requiring a substantive defense on the part of employers who impose them, plus an affirmative finding that they do not act to reduce wages or restrict job offers.

The same dynamic is at play in prohibitions on poaching in franchising agreements, which Alan Krueger and Orley Ashenfelter recently found to be prevalent in franchising contracts and which, to my knowledge, the federal competition regulators have never touched—even though they do regulate other provisions of those contracts. Franchising networks are a hybrid beast, somewhere between horizontal and vertical, but a blanket prohibition on poaching throughout a franchisor’s network certainly starts to look like a horizontal agreement not to compete.

It’s important to understand, though, that these written restraints of trade are symptoms of the broader decline in worker power, and meaningful antitrust enforcement should go after the causes. Reclassification of workers as independent contractors is a broader concern—not only anti-competitive in itself, but as a means to engage in other coercive conduct and corporate structures. Studies show that reclassifications result in immediate wage reductions and no other changes in terms of employment, suggesting that they amount to employer’s exploiting their wage-setting power by changing the legal structure of their business.

And beyond the act itself, classifying workers as independent contractors allows employers to avoid liability for minimum wage, maximum hours, workplace safety, and a host of other entitlements associated with statutory employment. The idea was that employment inherently signifies control, and with control ought to come responsibility—and by extension, if employers do not bear responsibility, then they should not be able to exercise control. What employers have realized now, as enforcement regimes in both labor and antitrust have weakened, is that they can have the control without the responsibility. For example, contracting terms often prevent workers from simultaneously working for others—an exercise of control if ever there was one, and an anti-competitive vertical restraint in the context of an independent contractor.

Employers can have that control without first establishing themselves as a monopoly—in fact, reclassification is increasingly standard operating procedure in many industries, which means that treating it as a violation of Section 2 of the Sherman Act should not require that outright monopolization must first be shown.

This is the fundamental issue behind the litigation over whether Uber’s drivers ought to be considered employees, and if not, whether the business amounts to a price-fixing conspiracy between the company and hundreds of thousands of independent businesses who drive for it. I’ve written before about the antitrust lawsuit against Uber on these grounds. The case was recently dealt a severe blow in the form of an appellate ruling that upheld the company’s mandatory arbitration clause—meaning that if the lower court decides Uber did not itself void the arbitration clause by hastening the case with a move to summary judgment, then the case will likely be thrown out of court.

That brings us to yet another way in which employers exercise monopsony power: mandatory arbitration and class action waivers for employment claims, about which the Supreme Court is set to hear a case this term. The issue there is that expansive readings of the Federal Arbitration Act have essentially said that individual rights protected by both the constitution and federal statute can be voided by bilateral waivers—as though the parties are equally situated and at liberty to reject such provisions in employment agreements and elsewhere. Of course, the whole point of monopsony is that jobs are scarce, and hence employers have leverage with which to extract concessions, be they out-and-out wage reductions or agreements not to litigate disputes. Thus, another aim of antitrust enforcement in labor markets ought to be bans on litigation waivers between parties that are not similarly situated economically as restraints of trade—and the competition authorities ought to make their views known to the Supreme Court on this issue. After all, private action is a pillar of federal antitrust policy, and so arbitration clauses are not just themselves restraints of trade, but they also inhibit enforcement against other restraints, as the fate of the Uber antitrust case shows.

Finally, there’s the elephant in the room when it comes to antitrust: merger review, the bulk of what the agencies do about enforcing the laws they’re entrusted to carry out. Claims that mergers reduce employment are not entertained as arguments against them—in fact, they are likely to be considered arguments in favor, as they show some motivation for the transaction beyond raising prices for consumers. And yet we know anecdotally that recently-consummated mergers have in fact had adverse employment impacts. A systematic study of the labor market impact of past mergers has yet to be conducted, to my knowledge—such an exercise would be a valuable component of assessing the impact and success of the current competition policy regime, including whether these job losses do actually end up benefiting consumers in the form of lower prices, as merging parties invariably claim, versus their shareholders and executives.

In conclusion, the view that the competition authorities expressed to the OECD in 2015 looks increasingly out of touch with the labor market and the broader macroeconomic conditions that currently exist. It is true that redirecting antitrust enforcement to confront monopsony power would be a substantial departure from the way it has been conducted in recent decades, and as such there are both court decisions and agency policies that go against it. But just because a policy has been in place for a long time does not mean it is a success, and recent evidence implies a significant policy change is necessary and justified—much as an intellectual movement in academia once shifted antitrust policy substantially, it’s time for new evidence to change it once again.

Study: Hospitals on doctor-buying spree raise legal questions

http://www.healthcarefinancenews.com/news/study-hospitals-doctor-buying-spree-and-raises-legal-questions?mkt_tok=eyJpIjoiTkRWa1ptVTJNMlUyWldVeCIsInQiOiJGaXFrTXRvUlM4YjFhbHpsVUtRSEh2ZmlCaElBOXh0cVwvejFndVg1WnhTNjEzYmZnTjVIZVMrNjdPeEREOXc4R0I4V0pFN1VZSW5VQVNCYWEycjFIejlmSEZcL1V6VnJ2ZkpUd3k1ekhkY1BidzAyNWdDZGhwRlZacHNudExqclpwIn0%3D

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Bigger and fewer doctor practices drive up prices for patients, employers and taxpayers, several studies confirm.

Hospitals have gone on a doctor-buying spree in recent years, in many areas acquiring so many independent practices they’ve created near-monopolies on physicians.

Research published Tuesday throws new light on the trend, showing that large doctor practices, many owned by hospitals, exceed federal guidelines for market concentration in more than a fifth of the areas studied.

But it goes further, helping answer some of health policy’s frequently asked questions: How could this happen? Where are the regulators charged with blocking mergers that have been repeatedly shown to drive up the price of health care?

The answer, in many cases, is that they’re out of the game.

Doctor deals are typically far too small to trigger official notice to federal antitrust authorities or even attract public attention, finds a paper published in the journal Health Affairs.

When it comes to most hospital-doctor mergers, antitrust cops operate blind.

“You have a local hospital system and they’re going in and buying one doctor at a time. It’s onesies and twosies,” said Christopher Ody, a Northwestern University economist and one of the study’s authors. “Occasionally they’re buying a group of five. But it’s this really small scale” that adds up to big results, he said.

The paper, drawing from insurance data in states covering about an eighth of the population, found that 22 percent of markets for primary care doctors, surgeons, cardiologists and other specialties were “highly concentrated” in 2013. That means that, under Federal Trade Commission guidelines, a lack of competitors substantially increased those doctors’ ability to raise prices without losing customers.

The research didn’t sort physician groups by ownership. But other studies show that large, predominant practices are increasingly owned by hospitals, which see control of doctors as a way to both coordinate care and ensure patient referralsand revenue.

According to one study, hospitals owned 26 percent of physician practices in 2015, nearly double the portion from 2012. They employed 38 percent of all physicians in 2015, up from 26 percent three years earlier.

In the study by Ody and colleagues, only 15 percent of the growth by the largest physician groups from 2007 to 2013 came from acquisitions of 11 doctors or more.

About half the growth of the big practices involved acquisitions of 10 or fewer doctors at a time. About a third of the growth came not from mergers but from hiring doctors out of medical school or other sources.

Federal regulations require notification to anti-monopoly authorities only for mergers worth some $80 million or more — far larger than any acquisition involving a handful of doctors.

Very few of the mergers that drove concentration over the market-power red line — or even further — in the studied areas would have surpassed that mark or a second standard that identifies “presumably anti-competitive” combinations.

But the little deals add up. In 2013, 43 percent of the physician markets examined by the researchers were highly or moderately concentrated according to federal guidelines that gauge monopoly power by market share and number of competitors.

(A market with three practices in a particular specialty, each with a third of the business, would be at the lower end of what’s considered highly concentrated. A market with one doctor group doing at least 50 percent of the business would be highly concentrated no matter how many rivals it had.)

Bigger and fewer doctor practices, fueled largely by hospital acquisitions, do drive up prices for patients, employers and taxpayers, several studies confirm.

Part of the increase results from a reimbursement quirk. Medicare and other insurers pay hospital-based doctors more than independent ones. But another part comes from the lock on business held by large practices with few rivals, Ody said.

“It’s a problem,” said Martin Gaynor, a health care economist at Carnegie Mellon University and former head of the FTC’s Bureau of Economics. “All the evidence that we have so far … indicates that these acquisitions tend to drive up prices, and there’s other evidence that seems to indicate it doesn’t do anything in terms of enhancing quality.”

The American Hospital Association, a trade association, declined to comment on the study since officials hadn’t seen it. But the AHA often argues that “hospital deals are different” and that doctor acquisitions keep patients from falling through the cracks between inpatient and outpatient care.

The FTC has moved to block or undo a few sizable doctor mergers, including an orthopedics deal in Pennsylvania and an attempt by an Idaho hospital system to buy a medical practice with dozens of doctors.

But the agency largely lacks the tools to challenge numerous smaller transactions that add up to the same result, said Ody.

An FTC spokeswoman declined to comment on the study’s findings.

Ody urged state attorneys general and insurance commissioners to look more closely at doctor combos. Sometimes state officials can question mergers overlooked by federal authorities. Or they can block anti-competitive practices, such as when hospitals seek to exclude competitor physicians from insurance networks.

Beyond that, “I hope that people notice this [research], and I hope people think creatively about what kinds of solutions might be appropriate for this,” he said. “I don’t know what they are.”

Market power matters

Market power matters

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It’s the clash of titans.

In January the Massachusetts the Group Insurance Commission (GIC) — the state agency that provides health insurance to nearly a half-million public employees, retirees, and their families — voted to cap provider payments at 160% of Medicare rates. Ignoring Medicare (~1M enrollees) and Medicaid (~1.6M enrollees), the GIC is the largest insurance group in the state.  According to reporting from The Boston Globe, the cap would be binding on a small number of concentrated providers, including Partners HealthCare, one of the largest hospital systems in the state.

David Anderson summed the development up perfectly.

The core of the fight is a big payer (the state employee plan) wants to use its market power to get a better rate from a set of powerfully concentrated providers who have used their market power to get very high rates historically.

Anderson also pointed to a relevant, recent study that illustrates how a specific payer’s and provider’s market power jointly affect prices. In Health Affairs, Eric Roberts, Michael Chernew, and J. Michael McWilliams studied the phenomenon directly, which has rarely been done. Most prior work aggregate market power or prices across providers or payers in markets.

Their source of price data was FAIR Health, which includes claims data from about 60 insurers across all states and D.C. In a county-level analysis, the authors crunched 2014 data for just ten of those insurers that offered PPO and POS plans and that did not have solely capitated contracts. These ten insurers represent 15% of commercial market enrollment. They then looked at prices paid by these insurers to providers in independent office settings for evaluation and management CPT codes 99213, 99214, and 99215. These span moderate length visits to longer visits for more complex patients and collectively represent 21% of FAIR Health captured claims.

They computed insurer market share based on within-county enrollment. They computed a provider group’s market share as the county proportion of provider taxpayer identification numbers (TIN) associated with that group’s National Provider Identifier (NPI) — basically the size of group in terms of number of physicians.

Some of the findings are illustrated in the charts below and are largely consistent with expectations. For all three CPT codes, insurers with greater market shares tend to pay lower prices. That’s shown just below. The biggest price drop occurs when moving from <5% to 5-15% market share. Greater market share than that is associated with still lower prices, but not by as much. For example, insurers with <5% market share pay an average of $86 for CPT code 99213; insurers with 5-15% market share pay 18% less and insurers with ≥15% just a few percent less than that. It’s roughly the same story for other CPT codes.

Study: In healthcare price negotiation, insurer size matters

http://www.fiercehealthcare.com/payer/study-when-negotiating-healthcare-prices-insurer-size-matters?utm_medium=nl&utm_source=internal&mkt_tok=eyJpIjoiWmpCaVl6YzNZVGMzWW1VMSIsInQiOiJFOWcxQXlNRFltbXIzc2FocWNwREJpRnp6dEpLbmZORTVIb29WaTRtQ2lrYzVwQ1hjOW4rS1RMUDlNOEE1RVRJdEJoMjJYeEpNWUFjbnBiRUQ0WGhoSGpkUDQyWkQxZE1UQ3NBbFU1bjVwVm5ITjBTVUxRbmNWQ3JcLytnMlM0bnAifQ%3D%3D

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Larger health insurers are able to negotiate lower prices with providers, according to a new study. But that doesn’t necessarily mean payer consolidation is the answer to keeping healthcare costs in check.

The study, conducted by researchers from Harvard Medical School and published in the January issue of Health Affairs, examined multipayer claims data from 2014 to assess how insurers’ market power affected the rates that they were able to negotiate for office-based physician services.

The researchers found that greater market power did indeed give insurers a leg up at the negotiating table. For example, when examining rates for office visits paid to the same group of providers, they estimated that large insurers—those with market shares of 15% or more—negotiated prices that were 21% lower than prices negotiated by small insurers, or those with market shares of less than 5%.

Looking at providers of different sizes, the study also found evidence that insurers require greater market shares to negotiate lower prices from large provider groups than with smaller ones. And if providers respond to insurer mergers with greater consolidation of their own, that would boost their bargaining power and let them negotiate higher prices, the study said.

Is antitrust the answer to hospital consolidation?

Is antitrust the answer to hospital consolidation?

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robust literature on the benefits of competition in the health care marketplace shows that when health care markets are competitive, prices tend to be lower, quality tends to be higher, and people have more choices for care. Competition is a remarkably powerful tool that needs to be wielded more effectively. The good news is that ensuring competition is already the law of the land. The problem is that with the pace of consolidation, monitoring potential anticompetitive effects will be increasingly difficult as the FTC is tasked with examining a rapidly increasing number of mergers. The FTC needs renewed focus from policy makers to ensure that it can do its job effectively.

Catholic Health Initiatives, Dignity Health in Merger Talks

http://www.wsj.com/articles/catholic-health-initiatives-dignity-health-in-merger-talks-1477335251

Catholic Health Initiatives operates in 18 states, but not in Arizona, California and Nevada, where Dignity Health operates its hospitals. Above, Dignity Health California Hospital Medical Center in downtown Los Angeles.

Hospital operator Catholic Health Initiatives, which has struggled after rapid expansion and a foray into health insurance, is in merger talks with Dignity Health to create one of the nation’s largest nonprofit hospital systems by revenue.

Catholic Health Initiatives and Dignity Health said in a statement they are in talks regarding “aligning their organizations.” A person familiar with the matter said the talks involve a merger.

The deal would combine 103 hospitals owned by Catholic Health Initiatives, based in Englewood, Colo., with 39 hospitals operated by San Francisco-based Dignity Health. Combined revenue for the new organization would reach $27.8 billion annually, based on the most recent financial statements.

Healthcare mergers and acquisitions in 2016: Running list

http://www.healthcarefinancenews.com/slideshow/healthcare-mergers-and-acquisitions-2016-running-list?mkt_tok=eyJpIjoiWlRkaE16VTBPRGhrTmpWbSIsInQiOiIxRk44S3JKdEd3Mzl5czNscEJZNjI1N210RWE0b0RxNWd3RHhoZUg2TXJCM3U2QnZJWm1VcFhMS2daQ1pmRzEyTG5DU2E0cWFCdGtWQlJKS0N0NE51Y2FubWdZbWptcTRhVHRZaTZJNDM1VT0ifQ%3D%3D

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Dignity Health, CHI Explore ‘Alignment’

http://www.healthleadersmedia.com/leadership/dignity-health-chi-explore-alignment?spMailingID=9754012&spUserID=MTMyMzQyMDQxMTkyS0&spJobID=1021982472&spReportId=MTAyMTk4MjQ3MgS2#

 

 

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Potential merger would create a one of the nation’s largest non-profit health systems, with more than 140 hospitals and hundreds of clinics and physicians’ offices in two dozen states.

FTC puts an end to Penn State-PinnacleHealth deal

http://www.fiercehealthcare.com/finance/ftc-prevails-squelching-penn-pinnaclehealth-deal

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Thanks to the Federal Trade Commission, the Penn State Health and PinnacleHealth merger will not go forward.

Plans to merge were called off late last week, according to PennLive.com. The Penn State Board of Trustees voted unanimously to call off the deal, which would have created a four-hospital system in the Harrisburg region, including Penn State’s Hershey Medical Center and the three PinnacleHealth facilities.

The FTC and the Pennsylvania Attorney General intervened in the deal late last year, with both claiming that residents in Central Pennsylvania would have few alternatives for other healthcare providers, leaving the likelihood open that the merged entity would raise prices. Thetransaction was initially approved by a U.S. District Court in May, but the parties were dealt a blow when the ruling was reversed by the U.S. Third Circuit Court of Appeals last month.

The aborted deal cost Penn State an estimated $17.6 million in legal fees and other costs, according to PennLive.

The case is part of what has been heightened scrutiny of recent hospitals deals by both federal and state regulators. In November, the FTC intervened in a deal between two rural hospitals in West Virginia, Cabell Huntington Hospital and St. Mary’s Medical Center. The agency recently prevailed in a 2010 case where it intervened in ProMedica’s acquisition of St. Luke’s Medical Center in Toledo, Ohio. The agency is also fighting a proposed merger between Advocate Health Care and NorthShore University HealthSystem in Chicago, although as in the Penn State matter, it has lost at the lower court level.

FTC Chairwoman Edith Ramirez expressed concern earlier this year that ongoing hospital mergers will soon impact healthcare pricing around the U.S., but deal-making appears to go on unabated. That’s despite the fact that a recent analysis suggested that mergers even across markets can lead to double-digit cost increases.

DOJ says Aetna, Humana are trying to derail antitrust case

http://www.bizjournals.com/louisville/news/2016/10/11/doj-says-aetna-humana-are-trying-to-derail.html

Lawyers for the U.S. Department of Justice say Aetna Inc. and Humana Inc are trying to derail the government's antitrust challenge of Aetna's proposed $37 billion acquisition of Humana.

Lawyers for the U.S. Department of Justice say Aetna Inc. and Humana Inc are trying to derail the government’s antitrust challenge of Aetna’s proposed $37 billion acquisition of Louisville-based Humana.

This comes after lawyers for the companies accused the DOJ with “serious delay and misconduct” last week. The companies requested sanctions, claiming that the government withheld about 1 million documents and that this had “gravely undermined” the companies’ ability to mount a defense against claims that the acquisition would hurt competition.

The National Law Journal reports that the government’s response came Saturday in a court filing, in which it said the DOJ has tried to accommodate the “broad and extremely burdensome discovery demand” from Aetna (NYSE: AET) and Humana (NYSE: HUM) on the U.S. Department of Health and Human Services.

The government called the request for sanctions “a transparent attempt to derail the United States’ merger challenge before the district court ever hears from a single witness or reviews any evidence,” the law journal reported.

At issue is how much market share the combined company would control in Medicare Advantage, a type of Medicare plan offered by a private insurer. A court date is set for Dec. 5, 2016, and the judge says a decision isn’t likely until mid-January 2017 — past the companies’ end-of-year deadline to close the deal.