Health care and corporate finance

Towner, Mitch Scott
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This dissertation examines issues in U.S. healthcare and capital structure. In the first chapter I give a brief summary of the institutional details of the U.S. healthcare sector with a special emphasis on healthcare finance. In addition to its large size, U.S. healthcare has four unique features that can be used to help answer corporate finance questions: segmented markets, variation in corporate type, extensive data requirements and recent consolidation. I explain how changes over the last 100 years have led to each of these features. Next, I delve deeper into bargaining between insurance companies and hospitals, Medicare pricing, and hospital capital structure decisions during my sample period, 2008-2012. Finally, I conclude with a brief discussion on how the Affordable Care Act has contributed to these factors. In the second chapter I use the health care industry as a novel laboratory in which to study a firm's strategic use of debt to enhance their bargaining power during negotiations with non-financial stakeholders. I show that reimbursement rates negotiated between a hospital and insurers for a specific procedure are higher when the hospital has more debt. I also show that this effect is stronger when hospitals have less bargaining power relative to insurers ex ante, and that hospitals take on more debt when they have less bargaining power using six proxies including differences in state Medicare laws to further strengthen identification. This is the first paper to provide direct evidence that debt improves a firm's bargaining outcomes.