DemonstrativesProfessorDavidDranove FINAL PUBLIC

8/12/2019 DemonstrativesProfessorDavidDranove FINAL PUBLIC

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Demonstratives for the testimonyof Professor David Dranove

FTC & State of Idaho v. St. Lukes Health System & Saltzer Medical GroupNo. 1:13-cv-00116

October 2, 2013


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1. Background and introduction

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Qualifications Education

PhD, Economics, Business, and Policy, Stanford UniversityMBA, Cornell University

BA, Genetics, Cornell University

Academic workResearch focuses on competition in healthcare marketsDirector of the Health Enterprise Management Program, Kellogg School of

ManagementWalter McNerney Distinguished Professor of Health Industry Management, KelloggSchool of Management; Department of Economics at Northwestern University

Associate Professor at the University of ChicagoOver 50 peer reviewed journal publications, 5 books

Expert testimonyPeoria Day Surgery Center v. OSF Healthcare SystemMessner v. Evanston Northwestern Healthcare Corporation

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Scope of assignment The FTC and the State of Idaho asked me to conduct an

economic analysis of the likely effects on competition andconsumer welfare caused by St. Lukes Health Systemsacquisition of the Saltzer Medical Group

My examination of this question is independentMy compensation is based on time and not contingent onoutcome or my conclusions

I worked with a support staff from Bates White EconomicConsulting

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Evidence considered Testimony from all categories of market participants

Health plans, providers, employers

Ordinary course of business documents from themerging parties and third parties

e.g., strategic plans, correspondence

Claims data produced by Blue Cross of Idaho, RegenceBlue Shield, and PacificSource (IPN)

A wide array of published health economics literature

Analyses and evidence from Defendants experts

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2. St. Lukes and Saltzer

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Nampa and the Treasure Valley

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3. Analytic framework

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Selective contracting and two-stage competition


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Selective contracting In healthcare provider markets, prices are determined in selective

contracting negotiations between providers and health plansNegotiations primarily focus on total reimbursements

Negotiations determine which providers are in-networkPatients have a strong financial incentive to select in-network providers

In any bargaining setting, as one party to a negotiation gains greaterleverage, it will be able to negotiate more favorable terms

Leverage is generally determined by each partys outside option i.e.,the Best A lternative To a Negotiated A greement ( BATNA )

Providers with greater bargaining leverage can negotiate higher totalpayments (i.e., reimbursements) from health plans, generallythrough an increase in prices

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Draft--Preliminary wor k pr oduct

Increased provider leverage harms consumers

Provider withincreasedleverage

Higherpremiums

HealthPlans pay

more

Local employersand consumers

pay more(e.g., out-of-pocket costs)

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Higher negotiatedrates for services


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4. Relevant product market

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The relevant product market is Adult PCP services


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Market definition and the Horizontal Merger

Guidelines The goal of market definition is to identify a set of sellers that are

close substitutes, while excluding sellers that are notThe Horizontal Merger Guidelines outline the framework the FTC and

DOJ use to analyze mergersCreated by antitrust economists and attorneys, with broad input fromstakeholders and widely adopted as an analytical framework by courts

The Agencies, antitrust economists, and courts follow the Guidelineshypothetical monopolist or SSNIP test to define marketsHypothetical monopolist test: Could a hypothetical monopolist of allfirms in the proposed market profitably impose at least a Small butSignificant and Non-transitory Increase In Price (SSNIP) ?

If the SSNIP is not profitable, the market should be expandedIf the SSNIP is profitable, the market is properly defined

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The relevant product market is Adult PCP services

No material dispute that adult primary care physician services soldto commercially insured patients (Adult PCP services) is a relevantproduct market (Argue Report, 100)

Adult PCP services is a relevant product market because ahypothetical monopolist of all Adult PCPs would be able toprofitably impose a SSNIP

To offer competitive products, health plans require Adult PCPs in their

networks, and other specialties are not sufficiently substitutable

Adult PCP services is a relevant product market, even though somepatients see other types of physicians for primary care

e.g., some women see OB-GYNs, but health plans could not assemble aviable provider network with OB-GYNs but no Adult PCPs

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5. Relevant geographic market

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The relevant geographic market is Nampa


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Nampa is the relevant geographic market

Hypothetical monopolist of all Adult PCPs in Nampacould profitably impose a SSNIP

Multiple, consistent points of support for Nampa as arelevant geographic market

Evidence from broad range of market participants that patientsprefer local access to primary care physicians

Every health plan, including St. Lukes health plan partner,recognizes the importance of including Nampa PCPs in-networkData show a clear distinction between Nampa and Boise

All major health plans have PCPs very close to where their

members live

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Health plans need local PCPs in-network

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ATTORNEYS' EYES ONLY


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St. Lukes analyzed the Nampa Physician Market

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TX 1115 at Slide 6Note: St. Luke's acquired the "Mercy Group" physicians in 2011 and Saltzer in 2012


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Some patients do travel

Idiosyncratic factors often explain patient travelPatient has moved, PCP has moved, personal relationshipsPatients may select a PCP near their work

Generally, observed patient travel is not the result of smalldifferences in price

e.g., BCI uniform pricing schedule

Therefore, such travel is not a reliable predictor of priceresponses

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Dr. Argues geographic market analyses are flawed

Dr. Argue never posits a well-defined relevant geographicmarket

Dr. Argue's attempt to greatly expand the geographic market toinclude at least Nampa, Caldwell, Meridian, and West Boise is incorrect and lacks a consistent empirical basis

Dr. Argue relies almost entirely on patient flow analysisIgnores industry structure and economic research demonstrating thatpatient flows alone are an inappropriate basis for evaluating theprofitability of a SSNIPBoth Dr. Argues original critical loss analysis and his revised critical

loss analysis are inapt and flawed

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6. Market shares,concentration, andcompetitive effects

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The acquisition substantially lessens competition

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The acquisition substantially lessens competition The acquisition will substantially increase concentration

in a market that is already highly concentratedWill increase St. Lukes/Saltzers leverage in negotiations withhealth plans, facilitating price increasesHealth plans best alternative, or outside option, to contractingwith St. Lukes is much less attractive after the acquisitionConsistent with this, the increase in concentration is

presumptively anticompetitive under the Merger Guidelines

Testimony and documents support these conclusions

Diversion analysis shows that for Nampa residents, St.Lukes and Saltzer are each others closest substitute

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Horizontal Merger Guidelines concentrationthresholds

1. Unlikely to have adverse competitive effects :HHI increase below 100 points, orPost-merger HHI below 1500

2. Potentially raise significant competitive concerns :Post-merger HHI between 1500 and 2500, andIncrease in HHI over 100

3. Presumed likely to enhance market power :Post-merger HHI over 2500 , andHHI increase over 200 points

Presumption may be rebutted by persuasive evidence showingthat the merger is unlikely to enhance market power

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Horizontal Merger Guidelines (2010)


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7. Entry and expansion

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Entry and expansion are unlikely to offset theanticompetitive effects of the acquisition


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Expansion is also unlikely to offset the47


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Expansion is also unlikely to offset theanticompetitive effects of the Saltzer acquisition

Difficult for existing in-network PCPs to expand theirpractices by cutting price

Saint Alphonsus has had little success expanding its Nampa PCP

presence

Suppose the combined St. Lukes/Saltzer increasesprice, and an insurer considers terminating in response

The insurer will need other Nampa-based PCPs, or it will struggleto compete against other insurers Absent termination of St. Lukes/Saltzer, an existing PCP groupwould be unlikely to add PCPsBut until an existing PCP group expands, it would be difficult foran insurer to terminate St. Lukes/Saltzer

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Deposition of Thomas Reinhardt at 47-50

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8. Vertical integrationand efficiencies

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Theory and evidence indicate that theSaltzer acquisition is unlikely toresult in efficiencies


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Assessing the evidence from St Lukes prior PCP50


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Assessing the evidence from St. Luke s prior PCPacquisitions

Experiment : A systematic, empirical analysis of the effects of St.Lukes past acquisitions of PCP groups Use insurers claims data to test whether St. Lukes PCP acquisitions

reduced overall healthcare costs for the affected patients i.e., test theassertions of Dr. Argue and Professor Enthoven

Methodology : Difference-in-differences Compare changes in overall healthcare spending for patients in two groups:

Treatment group: patients under the care of PCPs acquired by St. LukesControl group: patients under the care of comparable non-acquired PCPs

Findings : No evidence of systematic reductions in healthcare costsfollowing St. Lukes past acquisitions of PCP groups

Indeed, results suggest that St. Lukes past PCP acquisitions may haveresulted in increased healthcare spending

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9. Summary

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Summary of conclusions

1. Bargaining and selective contracting are the appropriate economicframeworks for evaluating the Saltzer acquisition

2. Nampa is the relevant geographic market, and even if the market isexpanded significantly, my conclusions are the same

3. High market concentration indicates that the acquisition is likely tobe anticompetitive

4. Economic analysis and record evidence confirm that enhancedmarket power is highly likely

5. Acquisition will likely lead to higher healthcare costs to localemployers and consumers

6. Entry and expansion are unlikely to offset St. Luke's additionalmarket power

7. No basis to expect that the acquisition will likely lead to efficiencies

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Documents

DemonstrativesProfessorDavidDranove FINAL PUBLIC