_.au. COMPETITION IN THE HEALTH (~ARE SECTOR: Federal Trade (~ommission. Past., Present., and Future. Proceedings oj a Conference

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1 Federal Trade (~ommission b _.au. COMPETITION IN THE HEALTH (~ARE SECTOR: Past., Present., and Future Proceedings oj a Conference Sponsored by the Bureau of Econom,ics March 1978

2 COMPETITION IN THE HEALTH CARE SECTOR: PAST, PRESENT, AND FUTURE Proceedings of a Conference Sponsored by the Bureau of Economics, Federal Trade Commission Edited by Warren Greenberg March 1978

3 Federal Trade Commission MICHAEL PERTSCHUK, Chairman PAUL RAND DIXON, Commissioner ELIZABETH HANFORD DOLE, Commissioner DAVID A. CLANTON, Commissioner DARIUS W. GASKINS, JR., Director of Bureau of Economics JAMES M. FOLSOM,.Deputy Director EDWARD EITCHES, Assistant to the Director KEITH B. ANDERSON, Assistant to the Director MICHAEL W. KLASS, Assistant Director for Economic Evidence P. DAVID QUALLS, Assistant Director for Industry Analysis WILLIAM H. SPRUNK, Assistant Director for Financial statistics This is a staff report, prepared by the Commission's Bureau of Economics. The Commission has not adopted the report in whole or in part. Hence, all statements, conclusions, and recommendations contained herein are solely those of the staff responsible for its preparation. II

4 ACKNOWLEDGEMENTS I would like to thank former Director of the Bureau of Economics, Darius Gaskins, Jr., Commissioner of the Federal Trade Commission, Calvin Collier, and Chairman of the Federal Trade Commission, Michael Pertschuk, for their support given to me in conducting the conference and editing these proceedings. Michael Klass, Assistant Director, Economic Evidence, Bureau of Economics, also provided encouragement and allowed me time to complete these extra-curricular tasks. Finally, my secretary, Diane Hammond, went way beyond her secretarial duties and provided excellent administrative assistance. I would also like to thank Bess Townsend of the Federal Trade Commission for her diligent editorial pen and Betsy Zichterman and Ron Lewis, Supervisor, Qf the Word Processing Center of the FTC's Bureau of Economics for their important contribution in typing the most difficult sections of this manuscript. III

5 ACKNOWLEDGEMENTS SUMMARY TABLE OF CONTENTS III 1 REMARKS Michael Pertschuk REMARKS..... Theodore Cooper PART ONE Opening Remarks and Introduction : IS MEDICAL CARE DIFFERENT? 19 Mark V. Pauly COMMENT ON THE PAPER Burton A. Weisbrod PART TWO Competition in Selected Sectors COMPETITION AMONG PHYSICIANS Frank A. Sloan and Roger Feldman COMMENT ON THE PAPER Donald E. Yett COMMENT ON THE PAPER Uwe E. Reinhardt.', IV

6 TABLE OF CONTENTS (continued) COMPETITION AMONG HOSPITALS David -So Salkever COMMENT ON THE PAPER John A. Rafferty COMPETITION AMONG HEALTH INSURERS H.E. Frech, III; and Paul B. Ginsburg COMMENT ON THE PAPER Howard Berman COMMENT ON THE PAPER David Robbins PART THREE Insurance, Competition, and Alternative Delivery Systems THE STRUCTURE OF HEALTH INSURANCE AND THE EROSION OF CO~PETITION IN THE MEDICAL MARKETPLACE 270 Joseph P. Newhouse THE EMERGENCE OF PHYSICIAN-SPONSORED HEALTH A HISTORICAL PERSPECTIVE Lawrence G. Goldberg and Warren Greenberg INSURANCE: COMPETITION OF ALTERNATIVE DELIVERY SYSTEMS. Alain C. Enthoven 0 COMMENT ON THE PAPERS Stu~rt o. Schweitzer v

7 TABLE OF CONTENTS (Continued) PART FOUR Competition and Regulation ROLE OF COMPETITION IN COST CONTAINMENT Clark C. Havighurst COMMENT ON THE PAPER John Pisarkiewicz, Jr. COMMENT ON THE PAPER Richard E. Shoemaker COMMENT ON THE PAPER Jesse L.Steinfe1d REGULATION AS A SECOND BEST..... Stuart H. Altman and Sanford L. Weiner COMMENT ON THE PAPER Harold A. Cohen GUILDS AND THE FORM OF COMPETITION IN THE HEALTH CARE SECTOR Lee Benham COMMENT ON THE PAPER Anne R. Somers VI

8 SUMMARY These Proceedings stem from a conference conducted by the Bureau of Economics, Federal Trade Commission (FTC), on June 1 and 2, 1977, in Washington, D.C. Attended by more than 600 people, the conference was an effort by the Bureau to explore and evaluate, with solicited papers from economists and social scientists, the role of competition in the health care sector. The views expressed at the conference do not necessarily reflect the views of the Bureau of Economics or the FTC but, instead, consistent with the complexity of the subject, represent the diversity of viewpoints of the participants from the FTC, from HEW, academic institutions, labor, the private sector, and nonprofit institutions. Furthermore, the papers differ in their use of technical jargon and mathematical exposition common to most economists, and language suitable for non-economists and public po1icymakers. This schizophrenia is, in part, due to my instructions to the economist-authors to remain true to our profession while respecting the nontechnical background of most of the audience. ~As with most gatherings of economists and social scientists, no unanimity was reached with respect to public policy toward health care. Indeed, the conference highlighted how much we do not know about the proper doses of competition which might be injected into this industry, although there were examples in many of the papers suggesting how competition- both price and nonprice--might be expanded. The Proceedings are divided into four sections: (1) opening remarks and introduction, (2) competition in selected sectors, (3) insurance and alternative delivery systems, and (4) competition and regulation. In each section the main papers are followed by one, two, or three shorter comments. Although a broad range of topics is covered, the limits of conference time prevented the inclusion of several areas of wide interest such as the pharmaceutical, dental services, and para7physician services markets. 1

9 I. Opening Remarks and Introduction In his opening remarks FTC Chairman Michael Pertschuk stres~e~ the importance of the health care industry, but acknowledges that the costs of health care are constraints of which we should be cognizant. Pertschuk suggests that health care can be classified as a business, but, nevertheless, the -concept" of competition in health care must be -responsibly explore[d]" by the FTC. Theodore Cooper, former Assistant Secretary for Health, and current Dean of the Medical College and Provost for Medical Affairs, Cornell University, agrees that -economic factorsare important in health policy deliberations. Cooper does note, however, that the FTC emphasis on competition in the medical marketplace is at variance with that of Congress and the current Administration. Cooper also asserts that competition does exist in the health care sector--such as the competition for patient referrals--but differs from price competition usually envisioned by economists. A central tenet of economic theory is that resources which produce goods and services will flow to the lines of endeavor in which the highest returns can be captured. All things held constant, an increase or decrease in the supply of goods or services will decrease or increase the price of the goods or services. In contrast, all things held constant, an increase or decrease in the demand for goods or services will increase or decrease the price of goods or services. These basic laws of supply and demand have such powerful predictive power that many economists believe their theoretical framework can be applied to any industry in the economy. Is the medical care industry or health care sector different? Are there market imperfections which inhibit the laws of supply and demand from operating and which make impossible the economists' goal of an optimal use of resources? If there are such restrictions, antitrust public policy, which has a pro-competitive bias, may be inappropriate for segments of the medical sector. Mark Pauly answers yes, no, and maybe to the query -Is Medical Care Different?" depending on the extent of consumer experience with an illness or unexpected illness and the type and scope of medical care contacts with physicians. It is the absence of information of the appropriate price-quality level that is the most important "potential- difference between medical care and other goods. Burton Weisbrod, commenting on Pauly's paper, suggests that the usual efficiency criteria employed by economists are not necessarily adequate for the health industry; in his view health and medical care may be 2

10 different because of the public's concern with distributional access (not usually considered by economists) rather than allocative efficiency. Further, Weisbrod contends that the difficulties consumers have in evaluating medical services should.caution public policymakers that any goal o-f stimulating competition through more informatipn should include both price and quality information to consumers. II. Competition in Selected Sectors The imperfections of information are stressed again in Competition among Physicians by Frank Sloan and Roger Feldman. The authors devote a considerable portion of the paper to analyzing the extent to which physicians can create their own demand. Although any alleged ability of physicians to create their own demand must take into account a reduced net price that patients pay in the presence of insurance coverage, surely some of this alleged creation in noncovered physician services must be due, in part, to consumer ignorance. Sloan and Feldman use standard economic analysis--termed the neoclassical framework of economists--to evaluate previous economics literature on the ability of physicians to create their own demand. Although they conclude there is some empirical evidence to suggest that physicians can create their own demand, it is not clear that all explanatory variables are accounted for in order to make a definitive judgment. Sloan and Feldman point to elements in the market for physicians' services that, in their opinion, might be deemed monopolistic. Advertising prohibitions have made comparison shopping difficult and may contribute to a wide dispersion of physician fees and consequent monopoly power. The role of the medical society's relationship with Blue Shield is suspect, whereas physician-promulgated relative value scale pricing techniques are found to be relatively innocuous. Finally, Sloan and Feldman remark on restrictions and licensing requirements of nonphysician providers, suggesting that they often appear to serve the financial interest of physicians. Uwe Reinhardt devotes most of his comment to the methodology, assumptions, and conclusions of the Sloan-Feldman exposition of the physician-induced demand controversy. Reinhardt perceives a bias toward the neoclassical or traditional school in the Sloan-Feldman paper as opposed to the Parkinsonian school which allow for increases in demand from factors other than changes in price. Demonstrating that econometric research will reach equivocal results in most cases, even a well-fitted equation (a significant positive partial correlation coefficient between physician fees and the physician-population ratio indicating a physician's ability to induce demand) will be clouded by the physician's ability to order ancillary services 3

11 and diagnostic tests. Furthermore, even if econometric research could demonstrate that there is some market-determined limit to the physician's price-output policy (as there must be) one would not know whether or not the treatmen~s delivered at that limit include useless services. Reinhardt concludes that -tracer analysis,- which evaluates the entire treatment of various conditions under various alternatives, may be the best solution to understanding the physician-induced demand controversy. Donald Yett, like Owe Reinhardt, focuses on the Sloan Feldman treatment of the physician's ability to create his own demand. Yett believes that complex socioeconomic variables associated with physician conduct makes it difficult to isolate monopoly power even if significant partial correlations can be found between physician-population ratios and per capita utilization. Indeed, Yett is inclined to question all of Sloan and Feldman's empirical evidence which assumes monopoly power by the physician. David Salkever concludes that competition does exist in the hospital services market but is -based primarily upon the availability and sophistication of services and facilities rather than price.- Since this type of competition tends to raise rather than lower price, modifications in insurance arrangements, the financing mechanism that accounts for more than 90 percent of expenditures on hospital services, must be made in order to move toward a semblance of price competition. Salkever does caution, however, that even wit~ a change in the amount and type of insurance, the role of the physician in admitting patients and the high degree of hospital concentration found in many local markets can impede competition. John Rafferty endorses Salkever's view that a focus on insurance mechanisms for hospital reimbursement is the most important issue for competition among hospitals. Rafferty warns, however, that a stress on price-oriented competition may pose problems for maintaining a given level of quality care. III. Insurance and Alternative Delivery Systems When examining the performance of firms in an industry, most economists focus on the rates of return and' output of the leading firms. Typically, the firms that are studied are those which have profit-maximizing incentives. In their paper, B.E. Frech and Paul Ginsburg analyze the not-for-profit firms. Frech and Ginsburg find that Blue Cross, because of its exemption from property and premium taxes in some States and its exemptions 4

12 from required reserves and other regulatory requirements, have developed -administrative slack- in the operation of their Plans. Furthermore, Frech and Ginsburg maintain that because Blue, Cross and Blue Shield are beholden to hospital and physician providers there are incentives for them to sell a more complete version of insurance than the commercial carriers. The effect of Blue Cross in the health insurance market is to raise hospital prices rather than control costs. Rising prices of hospital services are of serious concern and public policy, according to Frech and Ginsburg, should consider a removal of the advantages Blue Cross enjoys vis-a-vis the commercial insurers. Not surprisingly, David Robbins of the Health Insurance Association of America commends the Frech-Ginsburg analysis since their policy prescriptions are generally to put Blue Cross on an equal footing with the commercial insurers. Robbins does suggest, however, that the Frech-Ginsburg paper leaves out a significant explanation of the market power of Blue Cross~ viz., the lower prices, co~pared to commercial insurers, that Blue Cross negotiates with hospitals for hospital services. Administrative slack or inefficiency, allegedly shown by Frech-Ginsburg, is disputed by Blue Cross Association's Howard Berman. Berman cites a 1975 Government Accounting Office analysis which shows that commercial insurers are less efficient than Blue Cross, and a March 1976 Social Security Bulletin study which suggests that Blue Cross has the lowest ratio of operating expense as a portion of premium income of all insurers. Insurance reduces the net price of services to the consumer~ assuming the usual downward sloping demand curve, more services will be demanded in the presence of insurance than without insurance (although, of course, the consumer must bear the cost of increased premium rates in the long run). In addition, more services will be demanded at each of many possible prices which shifts the entire demand curve and raises prices of services. Joseph Newhouse concentrates on another effect of insurance, that of induced technological change, which tends to -increase the rate of medical care price and expenditure increases relative to the competitive market.- Newhouse's model would predict a faster rate of price increase in services covered, in most part, by insurance compared to medical services less heavily covered by insurance. Newhouse claims that his results are consistent with the view that a competitive model has been eroded for hospital services (heavily covered by insurance) compared to physician, dental, and drug services less heavily covered by insurance. Therefore, Newhouse expects that hospital prices and expenditures could continue to increase at -above average" rates for a long period of time. 5

13 In their paper Lawrence Goldberg and Warren Greenberg examine competition that once existed in the 1930's among for-profit insurers before a physician-sponsored health insurance plan entered the market. This form of competition was based on cost control efforts that Goldberg and Greenberg relate in their description of insurance firms que~tioning the procedures and methods of physicians. They suggest that the emergence of a physician-sponsored health insurance plan, Oregon Physicians' Service, put an end to competitive cost control efforts by the private for-profit insurers. A final paper in the session on Insurance, Competition, and Alternative Delivery Systems provides examples of how HMO's might compete and illustrations of competition among alternative delivery systems. Alain Enthoven suggests that imperfections in the health industry are such that -simple generalizations- about the competitive impact of HMO's are -almost impossible to sustain.- Enthoven does suggest that HMO's be put on an equal footing with fee-for-service and -the subsidy of more costly systems of care through Medicare, Medicaid, and the tax laws be eliminated. In general, Enthoven believes that the government must take positive action to create a fair market test between the fee-for-service sector and alternative delivery systems. Stuart Schweitzer, in reviewing the Goldberg-Greenberg and the Enthoven papers, citing a theory of economics known as the -Theory of the Second Best, cautions that injecting doses of competition in only ~ections of the complex health care industry might not lead to more efficiency in the entire industry. In addition, Schweitzer asserts that the Goldberg Greenberg paper, which examines competition among for-profit insurers, and the Enthoven paper, which examines competition between health maintenance organizations and the fee-forservice sector, although both -thoughtful- and -carefully drawn, suffer from an absence of empirical evidence which would shed light on their plausibility. IV. Competition and Regulation The final section of the volume addresses the policy alternatives of competition and regulation in the health care sector. To what extent might these policies complement or conflict with each other in achieving quality care at reasonable cost? Economists have a predisposition toward competitioni yet, if enough imperfections exist in the market, regulation can conceivably be a preferable ''second-best'' alternative. To achieve a broad spectrum of discussion, this section consists of a varied set of papers from s6holars and practitioners of different perspectives and persuasions. 6

14 Clark Havighurst espouses the view that more competition and less restrictive regulation would be the desired remedy to control health care costs and deliver the health care mix desired by consumers. He contends that the existence of laws which exempt health care premiums paid by employers from taxation acts as an incentive to employers to provide more health care benefits than are desired by consumers. Furthermore, Havighurst advocates strict enforcement of antitrust laws and the use of trade regulation rules by the FTC to discourage boycotts by medical societies and physicians of those insurance companies monitoring physician procedures. According to Havighurst, one of the most important endeavors that the antitrust authorities can undertake is to strengthen the market mechanism to enable the for-profit insurers to control costs. In contrast to Havighurst's relatively sanguine view of the role of competition in the health sector, Stuart Altman and Sanford Weiner embrace a more skeptical approach. They claim that existing incentives and laws make a return to market forces in health impossible; hence, public regulation must be the inevitable "second best" alternative. But, claim the authors, regulation which controls output rather than encouraging changes in physician and hospital incentives will not be fruitful. The most important way that incentives should be changed is an explicit organizational strategy that concentrates on behavior within the hospitals. The final paper deals wjth the similarities of 17th century guilds and present-day licensure and restrictive practices of the medical profession. Lee Benham believes that the guild philosophy is "still accepted in our attitude toward the role of competition, production and dissemination of information, and consumer choice." Benham is not hopeful about changing the effects of the guild system; rather, he believes that the benefits of the system will go to those most able to muster political support. The comments in the session on competition and regulation seem to be as varied as the institutions represented by the participants. John Pisarkiewicz,Jr., a member of the Federal Trade Commission staff, strongly endorses Havighurst's call for market forces and vigorous competition in this industry. But he adds a cautionary note when he suggests that the theoretical underpinnings of a free market for health care may be difficult to achieve in practice. Jesse Steinfeld, Dean of the School of Medicine, Medical College of Virginia, reiterated the view of many of the participants, suggesting that if our goal is improved health, emphasis should be on health education, exercise, avoidance 7

15 of tobacco, and other preventive techniques. In addressing the issue of competition, Steinfeld claims that competition exists in a form not considered by others at this Conference. There is, for instance, competition among students to be admitted to professional schools and competition among researchers to discover the causes of various diseases. Competition as a policy option of the Federal Government should only be pursued a~ part of an overall national health policy. Richard Shoemaker, Assistant Director, Department of Social Security, AFL-CIO, comments on the Havighurst paper by denying the "semblance of a market at all in the health industry." For example, the medical profession is a monopoly in the medical marketplace which prevents a free play of competitive forces. Shoemaker believes that the antitrust laws should be applied to this monopoly--one of the most important endeavors, in his opinion, that the FTC could undertake. Harold Cohen, Director, Health Services Cost Review Commission, State of Maryland, agrees with Altman and Weiner's paper that the effectiveness of regulation depends on changing the incentives of hospitals, physicians, and--cohen adds--iocal regulators. Cohen concludes by suggesting that Altman and Weiner's case for regu lation as a "second best" is not made. In fact, he says the potential physician dominance of regulation may make it the "first worst." Although endorsing competition as the most desirable method of resource allocation, Anne Somers, Professor, Department of Community Medicine, Rutgers Medical School, suggests two characteristics of the health care industry which might make this industry respond differently to doses of competition. First, for most of the medical care sector, the economist's assumption of the sovereign consumer is, in reality, a myth. Second, the government is "inextricably involved in virtually every aspect of the decisionmaking." Like Steinfeld, Somers believes the answer to quality care at lowest possible cost lies in a large-scale cooperative public-private effort and not necessarily in competition or regulation. 8

16 v. A Final Statement Are there themes common to the 10 papers and 12 comments on the state--past, present, and future--of competition in the health care sector? Can some tentative conclusions be reached? Although-strict unanimity is absent, I suggest the following as possible findings: (1) Competition does exist in the health care sector, but it is not necessarily the type of competition that exists in other industries or is helpful in restraining monopoly power. For example, competiton may take the form of new, and perhaps better, equipment and technical apparatus, without regard to cost considerations. Competition which tends to control the cost of medical care is not as apparent but it did exist once in the State of Oregon and might exist between HMO's and the fee-for-service sector. (2) There are several reasons for atypical competition in the health care industry. Among them are the pervasiv~ influence of government, the special role of the physician, and other peculiar characteristics of the industry. These latter characteristics include the lack of information from providers and the existence of insurance which reduces prices to consumers of health care services. Finally, the uncertainty surrounding medical care is so great that physicians themselves are unsure of many outcomes. (3) Although the health care industry may not conform to the economist's ideal of competitive behavior, there were no obvious answers as to what form appropriate public policy might take. However, most observers believe that, even in view of the health industry's special characteristics, antitrust has, at least, some place in public policy. At the same time most authors believe that current public policy, with its emphasis on regulation, is not working optimally and the desired amount of government intervention has not yet been found. (4) Finally, there was a stong consensus that more research is needed on competition in the health care industry. Most papers reflect the lack of empirical work on this industry and are only strong beginning steps in a better understanding of competition in the health care sector. 9

17 PART ONE OPENING REMARKS AND INTRODUCTION 10

18 REMARKS Michael Pertschuk Chairman, Federal Trade Commission As everyone must know, it's not easy to get a handle on the economics of health care, much less focus on the specific issue of competition. While there are examples of more flexibility in the field of physician training and practice- doctors' unions, prepaid group practices, community health cooperatives, free clinics, and so on--we have to admit that the practice of medicine remains one of the last strongholds of private entrepreneurship. Despite the large infusion of Federal, State, and local tax money into medical care, the physician population still operates with rather remarkable independence. But physicians ought not to be singled out either for special honor or opprobrium. The entire health community- the health industry, if you will--has become the object of careful scrutiny by the public guardians of the country's trust and treasure. We all need the health industry so very much; it's not an overstatement to say that our lives depend on a strong, vigorous, responsive health industry. But not at any price. Not at any price. That is our issue today and tomorrow. Accessible and affordable quality health care is something every American has come to expect. How many times in the past several years have consumers spoken of the Wright n to quality health care, as if it were the same as the right to education or to police and fire protection? Yet, those other essential public services are supported out of a general tax base and are administered by officials subject to the rule of the ballot box. No such controls are the rule in the health sector. Quite the contrary. The money is generated in a variety of ways: third-party payments, Government subsidies, reinsurance guarantees, private fund-raising, complex tax incentives, and old-fashioned cash fees for service. The providers of care are generally not public officials. They are answerable primarily to their colleagues--and there is great suspicion that such accountability is more apparent than real. We know we need them--but we also know that, thus far, we have failed to control the escalating costs of the health care they provide. 11

19 The Federal Trade Commission is not a health or medical agency. To paraphrase a President who was hardly our patron saint, Calvin Coolidge, -the business of the FTC is business. And we recognize, along with most Americans, that.the delivery of health care is business, an industry of vast proportions and vital effect. Health care has become our business. I have no apologies for that; in fact, one might ask, -What took the FTC this long?n An answer to that is embarrassingly simple: The Commission--like most other agencies of Government--was slow to admit that one possible way to control the seemingly uncontrollable health sector could be to treat it as a business and make it respond to the same marketplace influences as other American businesses and industries. Is it possible, for example, to give enough information to patients so that they may shop for the best care at the lowest price they can afford? Is it possible to promote prevention and wise self-care as an alternative to costly reparative medicine and highpriced prescription drugs and devices? Can health care be marketed under all the requirements for full disclosure and non-deception that other marketed services must fulfill? Would Gresham's Law dominate a health ma'rketplace in which providers compete on terms both of price and quality? We don't know the answers. No one--whether American or foreign-born--has experienced such a marketplace. Yet, of all the societies on earth today, ours would seem to be the only one that could still inject competition into the provisions of health care, allow prices to respond to consumer demand, and maintain standards of quality care that reduce or even eliminate the risk of death or disability. The FTC is now in the process of receiving documents subpoenaed from the American Medical Association and certain State and local medical societies. Our intention is to learn how self-regulation--professional control over voluntary and State agencies--really works. There is reasonable doubt that the medical profession, by itself or through friendly State governments, is completely open to innovation, competition, quality control, or consumer choice. We are also beginning the same process with the American Dental Association and several of the ADA's State and local affiliates. 12

20 We may conclude, one day in the future, that self-regulation--however inadequate--is better than stronger Government regulation. There is serious doubt that the Civil Aeronautics Board has been a boon to passengers. And after nearly 10 years of piled-on law and regulation, the Medicare and Medicaid' programs have benefited the providers of health care as much--and in some cases more--than they have benefited patients. Certainly Secretary Joseph Califano has indicated as much in the recent HEW reorganization which produced a new Health Care Financing Administration with a specific mission: to control the costs of Medicare and Medicaid before they completely control the rest of us. But it is far too early to draw any rigid conclusions. Those of us who sit on the Commission know that competition in the health sector is a concept we must responsibly explore. Our minds are open to the ideas that will come from such ground-breaking conferences as this one. I want to thank the many people who are coming together with us today and tomorrow to give of their time, their ideas, and their good will. I was delighted to learn from Warren that the fees charged by the lawyers and economists on our program are still lower than the fees charged by the physicians we are all talking about. Maybe the reason lies in the fact that there is still no "competition industry" that sets its own high fees. But it ~ould be dreadful if, several years from now, the FTC has to run another conference on "competition in the health care competition industry." We would have only ourselves to blame. 13

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