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The impact of vertical integration on health care delivery and costs: Evidence from physician–pharmacy integration

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  • Kakani, Pragya

Abstract

Vertical integration among health care providers is an increasingly common feature of U.S. health care. This study investigates the impact of vertical integration in the context of oncology practices launching in-house pharmacies dispensing high-cost oral cancer treatments using a stacked event study design. I find physician–pharmacy integration lowers point-of-sale drug prices paid by plans due to 1.0% lower prices at in-house pharmacies. I also find physician–pharmacy integration increases the number of patients filling new prescriptions by 6.2% and reduces time-to-fill for new prescriptions requiring prior authorization. These effects may arise because in-house pharmacies individually have limited bargaining power and because vertical integration decreases coordination costs, reflected by faster prior authorization.

Suggested Citation

  • Kakani, Pragya, 2025. "The impact of vertical integration on health care delivery and costs: Evidence from physician–pharmacy integration," Journal of Health Economics, Elsevier, vol. 104(C).
    • Handle: RePEc:eee:jhecon:v:104:y:2025:i:c:s0167629625001201
    DOI: 10.1016/j.jhealeco.2025.103085
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    1. Agha, Leila & Frandsen, Brigham & Rebitzer, James B., 2019. "Fragmented division of labor and healthcare costs: Evidence from moves across regions," Journal of Public Economics, Elsevier, vol. 169(C), pages 144-159.
    2. Amanda Starc & Ashley Swanson, 2021. "Preferred Pharmacy Networks and Drug Costs," American Economic Journal: Economic Policy, American Economic Association, vol. 13(3), pages 406-446, August.
    3. Darius Lakdawalla & Wesley Yin, 2015. "Insurers’ Negotiating Leverage and the External Effects of Medicare Part D," The Review of Economics and Statistics, MIT Press, vol. 97(2), pages 314-331, May.
    4. Amitabh Chandra & Jonathan Skinner, 2012. "Technology Growth and Expenditure Growth in Health Care," Journal of Economic Literature, American Economic Association, vol. 50(3), pages 645-680, September.
    5. Leila Agha & Keith Marzilli Ericson & Xiaoxi Zhao, 2023. "The Impact of Organizational Boundaries on Health Care Coordination and Utilization," American Economic Journal: Economic Policy, American Economic Association, vol. 15(3), pages 184-214, August.
    6. Guilherme C. Amado & Diogo C. Ferreira & Alexandre M. Nunes, 2022. "Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?," International Journal of Health Planning and Management, Wiley Blackwell, vol. 37(3), pages 1252-1298, May.
    7. Ericson, Keith Marzilli & Sacarny, Adam & Zhou, Annetta, 2023. "Dangerous prescribing and healthcare fragmentation: Evidence from opioids," Journal of Public Economics, Elsevier, vol. 225(C).
    8. Richards, Michael R. & Seward, Jonathan A. & Whaley, Christopher M., 2022. "Treatment consolidation after vertical integration: Evidence from outpatient procedure markets," Journal of Health Economics, Elsevier, vol. 81(C).
    9. Oliver Hart & Jean Tirole, 1990. "Vertical Integration and Market Foreclosure," Brookings Papers on Economic Activity, Economic Studies Program, The Brookings Institution, vol. 21(1990 Micr), pages 205-286.
    10. Rahman, Momotazur & Norton, Edward C. & Grabowski, David C., 2016. "Do hospital-owned skilled nursing facilities provide better post-acute care quality?," Journal of Health Economics, Elsevier, vol. 50(C), pages 36-46.
    11. Konetzka, R. Tamara & Stuart, Elizabeth A. & Werner, Rachel M., 2018. "The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes," Journal of Health Economics, Elsevier, vol. 61(C), pages 244-258.
    12. Christopher C. Afendulis & Daniel P. Kessler, 2007. "Tradeoffs from Integrating Diagnosis and Treatment in Markets for Health Care," American Economic Review, American Economic Association, vol. 97(3), pages 1013-1020, June.
    13. Emily Oster, 2019. "Unobservable Selection and Coefficient Stability: Theory and Evidence," Journal of Business & Economic Statistics, Taylor & Francis Journals, vol. 37(2), pages 187-204, April.
    14. Matthew S. Lewis & Kevin E. Pflum, 2017. "Hospital systems and bargaining power: evidence from out-of-market acquisitions," RAND Journal of Economics, RAND Corporation, vol. 48(3), pages 579-610, August.
    15. Sun, Liyang & Abraham, Sarah, 2021. "Estimating dynamic treatment effects in event studies with heterogeneous treatment effects," Journal of Econometrics, Elsevier, vol. 225(2), pages 175-199.
    16. Craig T. Peters, 2014. "Bargaining Power and the Effects of Joint Negotiation: The “Recapture Effect”," EAG Discussions Papers 201403, Department of Justice, Antitrust Division.
    17. Matthew S. Lewis & Kevin E. Pflum, 2015. "Diagnosing Hospital System Bargaining Power in Managed Care Networks," American Economic Journal: Economic Policy, American Economic Association, vol. 7(1), pages 243-274, February.
    18. Zarek Brot-Goldberg & Timothy Layton & Boris Vabson & Adelina Yanyue Wang, 2023. "The Behavioral Foundations of Default Effects: Theory and Evidence from Medicare Part D," American Economic Review, American Economic Association, vol. 113(10), pages 2718-2758, October.
    19. Leemore Dafny & Kate Ho & Robin S. Lee, 2016. "The Price Effects of Cross-Market Hospital Mergers," NBER Working Papers 22106, National Bureau of Economic Research, Inc.
    20. Goodman-Bacon, Andrew, 2021. "Difference-in-differences with variation in treatment timing," Journal of Econometrics, Elsevier, vol. 225(2), pages 254-277.
    21. Daniel Burkhard & Christian P. R. Schmid & Kaspar Wüthrich, 2019. "Financial incentives and physician prescription behavior: Evidence from dispensing regulations," Health Economics, John Wiley & Sons, Ltd., vol. 28(9), pages 1114-1129, September.
    22. Ciliberto, Federico & Dranove, David, 2006. "The effect of physician-hospital affiliations on hospital prices in California," Journal of Health Economics, Elsevier, vol. 25(1), pages 29-38, January.
    23. Baker, Laurence C. & Bundorf, M. Kate & Kessler, Daniel P., 2016. "The effect of hospital/physician integration on hospital choice," Journal of Health Economics, Elsevier, vol. 50(C), pages 1-8.
    24. Richard A. Hirth & Michael E. Chernew & Edward Miller & A. Mark Fendrick & William G. Weissert, 2000. "Willingness to Pay for a Quality-adjusted Life Year," Medical Decision Making, , vol. 20(3), pages 332-342, July.
    25. Blume-Kohout, Margaret E. & Sood, Neeraj, 2013. "Market size and innovation: Effects of Medicare Part D on pharmaceutical research and development," Journal of Public Economics, Elsevier, vol. 97(C), pages 327-336.
    26. Lin, Haizhen & McCarthy, Ian M. & Richards, Michael, 2021. "Hospital Pricing Following Integration with Physician Practices," Journal of Health Economics, Elsevier, vol. 77(C).
    27. Horn, Danea, 2025. "The incentive to treat: Physician agency and the expansion of the 340B drug pricing program," Journal of Health Economics, Elsevier, vol. 101(C).
    28. Boris Kaiser & Christian Schmid, 2016. "Does Physician Dispensing Increase Drug Expenditures? Empirical Evidence from Switzerland," Health Economics, John Wiley & Sons, Ltd., vol. 25(1), pages 71-90, January.
    29. Gal-Or, Esther, 1999. "The profitability of vertical mergers between hospitals and physician practices," Journal of Health Economics, Elsevier, vol. 18(5), pages 621-652, October.
    30. Caroline Savage Bennette & Anirban Basu & Scott D. Ramsey & Zachary Helms & Peter B. Bach, 2019. "Health Returns to Pharmaceutical Innovation in the Market for Oral Chemotherapy in Response to Insurance Coverage Expansion," American Journal of Health Economics, MIT Press, vol. 5(3), pages 360-375, Summer.
    31. Guy David & Evan Rawley & Daniel Polsky, 2013. "Integration and Task Allocation: Evidence from Patient Care," Journal of Economics & Management Strategy, Wiley Blackwell, vol. 22(3), pages 617-639, September.
    32. Caroline Savage Bennette & Anirban Basu & Scott D. Ramsey & Zachary Helms & Peter B. Bach, 2019. "Health Returns to Pharmaceutical Innovation in the Market for Oral Chemotherapy in Response to Insurance Coverage Expansion," American Journal of Health Economics, University of Chicago Press, vol. 5(3), pages 360-375, Summer.
    33. Ordover, Janusz A & Saloner, Garth & Salop, Steven C, 1990. "Equilibrium Vertical Foreclosure," American Economic Review, American Economic Association, vol. 80(1), pages 127-142, March.
    34. Capps, Cory & Dranove, David & Ody, Christopher, 2018. "The effect of hospital acquisitions of physician practices on prices and spending," Journal of Health Economics, Elsevier, vol. 59(C), pages 139-152.
    35. Callaway, Brantly & Sant’Anna, Pedro H.C., 2021. "Difference-in-Differences with multiple time periods," Journal of Econometrics, Elsevier, vol. 225(2), pages 200-230.
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    JEL classification:

    • I10 - Health, Education, and Welfare - - Health - - - General
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • L22 - Industrial Organization - - Firm Objectives, Organization, and Behavior - - - Firm Organization and Market Structure
    • L23 - Industrial Organization - - Firm Objectives, Organization, and Behavior - - - Organization of Production

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