Publications by Paul Ginsburg for Health Policy Center

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This Health Affairs article by Bob Berenson and co-authors applies scrutiny to the market power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Based on interviews in 12 U.S. communities, they find that so-called "must-have" hospital systems and physician groups are obtaining steep payment rates from insurers. Even in markets with dominant health plans, insurers have not been aggressive in constraining rate increases, perhaps because they can simply pass along costs to employers; the dominant insurers only need to get the most favorable rates, not low rates. These findings suggest a range of market and regulatory approaches should be examined to address growing provider market clout.

Faced with declining payment rates, California providers have implemented various strategies that have strengthened their leverage in negotiating prices with private health plans. When negotiating together, hospitals and physicians enhance their already significant bargaining clout. California’s experience is a cautionary tale for national health reform: It suggests that proposals to promote integrated care through models such as accountable care organizations (ACOs) could lead to higher rates for private payers. Because antitrust policy has proved ineffective in curbing most provider strategies that capitalize on providers market power to win higher payments, policy makers need to consider approaches including price caps and all-payer rate setting.

The resource-based relative value scale (RBRVS) adopted in Medicare in 1992 was intended to address distortions produced by payments based on physician charges. Medicare and an increasing percentage of private insurers now pay physicians based on the RBRVS payment system, which is maintained by the Centers for Medicare and Medicaid Services (CMS), relying on advice on service valuations by the American Medical Relative Value Scale Update Committee (RUC). The paper describes particular problems with the process used by CMS and the RUC and explains why reimbursement for primary care physicians continues to lag those of other specialties.

During the l980s and l990s the growth in the supply of neonatal intensive care beds in urban areas of the U.S. outpaced the need for care. Of greater concern, the number of beds in small NICU facilities continued to grow. Regulatory and practice characteristics are important in explaining this growth.(American Journal of Public Health 2002 January; 92(1): 119-124).

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