Preferred provider organizations and antitrust policy: some recent issues. 1986

L B Costillo

Preferred Provider Organizations (PPOs) have rapidly increased in number in response to soaring health care costs. Government antitrust enforcement agencies have encouraged the growth of PPOs because they help bring needed competition to the health care field. Antitrust problems in this area can generally be avoided by careful planning and counseling, but there are antitrust questions that are sometimes raised. Such issues include whether large PPOs can selectively deal with certain hospitals and refuse to deal with others; when exclusion of competing providers by provider-sponsored plans might be unlawful, and whether PPOs can be contract preclude participating providers from participating in competing plans. In analyzing such questions, one should look at whether there is an agreement among competing providers, whether the PPO has sufficient market power to cause anticompetitive effects, whether the restrictions in issue are motivated by an anti-competitive effects, whether the restrictions in issue are motivated by an anti-competitive purpose, and whether there are procompetitive (including efficiency enhancing) reasons for the arrangement. Another question that is frequently raised is when can provider members of a PPO jointly negotiate or set their reimbursement rates. The law is not clear on this subject. However, if the provider members of a PPO make significant financial contributions to the plan or otherwise share in the risk of adverse financial consequences resulting from the plan's operation, antitrust risks are lessened.

UI MeSH Term Description Entries
D007348 Insurance, Health Insurance providing coverage of medical, surgical, or hospital care in general or for which there is no specific heading. Group Health Insurance,Health Insurance,Health Insurance, Voluntary,Health Insurance, Group,Health Insurances,Insurance, Group Health,Insurance, Voluntary Health,Insurances, Health,Voluntary Health Insurance
D011243 Preferred Provider Organizations Arrangements negotiated between a third-party payer (often a self-insured company or union trust fund) and a group of health-care providers (hospitals and physicians) who furnish services at lower than usual fees, and, in return, receive prompt payment and an expectation of an increased volume of patients. Organizations, Preferred Provider,Preferred Provider Organization,Organization, Preferred Provider
D004465 Economic Competition The effort of two or more parties to secure the business of a third party by offering, usually under fair or equitable rules of business practice, the most favorable terms. Competition, Economic,Competitions, Economic,Economic Competitions
D004467 Economics The science of utilization, distribution, and consumption of services and materials. Consumer Price Index,Capital,Conditions, Economic,Consumption,Cost of Living,Easterlin Hypothesis,Economic Conditions,Economic Policies,Economic Policy,Economics, Home,Home Economics,Household Consumption,Macroeconomic Factors,Microeconomic Factors,Policies, Economic,Policy, Economic,Production,Remittances,Utility Theory,Condition, Economic,Consumer Price Indices,Consumption, Household,Economic Condition,Factor, Macroeconomic,Factor, Microeconomic,Factors, Macroeconomic,Factors, Microeconomic,Household Consumptions,Hypothesis, Easterlin,Index, Consumer Price,Indices, Consumer Price,Living Cost,Living Costs,Remittance,Theories, Utility,Theory, Utility,Utility Theories
D014481 United States A country in NORTH AMERICA between CANADA and MEXICO.
D014485 United States Federal Trade Commission An independent administrative agency concerned with maintaining competitive free enterprise by prohibiting unfair methods of competition and unfair deceptive acts or practices. Federal Trade Commission (U.S.),USFTC,Federal Trade Commission

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