1. Applying the Five Forces by Wesley Shu, text by D. Besanko et al.

2. Hospital Market in Chicago Area Thriving in 80s, then declined, recently on the rise

3. Internal Rivalry – Background about 70 hospitals, mostly independent, i.e., low Herfindahl index (HHI) Fierce internal rivalry, because Many competitors Production costs vary Substantial excess capacity – occupancy rate < 70% at many hospitals Stagnant or declining demand

4. Internal Rivalry – MCO Took Advantage Managed care organizations (MCO, insurance companies) took advantage: Contract with hospitals offering the most favorable rates Lower the co-pay to encourage patients to choose those hospitals Due to high price elasticity, demand increase – hospitals are more homogenous

5. Internal Rivalry – MCO Took Advantage Negotiations between MCO and hospitals were secret, hospitals in disadvantageous position Contracts are infrequent – hospitals assumed pressure

6. Internal Rivalry – Hospital Fought Back Established brand identity, e.g., Northwestern Medical Center Diversified into related products, e.g., skilled nursing services Differentiated their services, e.g., establishing cancer center, etc. Patients required hospital in neighborhood – increase loyalty Merger

7. Entry - Barriers Government regulation on new hospital construction Hospitals are capital intensive Brand identity not easy for new hospitals

8. Entry – The Other Side Chicago area grew Innovations allowed smaller niche hospitals

9. Substitutes and Complements Few inpatient services could be performed outside the hospitals But improvement in surgical techniques made it possible Outpatient diagnostic facilities (ODF) – substitutes But ODF can also be complement – hospitals already had technology and experience to do it – economies of scope

10. Suppliers Demand for nurses high, supply low Price rising for drugs and other medical supplies

11. Buyers Insurers wield substantial power Insurers are large size – high negotiation power, e.g., Blue Cross and Medicare Highly skilled physicians became strong buyers who brought patients

12. Overview ForceThreat to Profit, 1980s Threat to Profit, today Internal rivalryLowHigh but falling EntryLowMedium but growing Substitutes and complements MediumHigh Supplier powerMedium Buyer powerLowMedium

13. Pentagonal Analysis

14. Use of Pentagonal Analysis Compared the intensity of competition of two industries (or the same one, different time) Entry strategy and decision for entrant, ex. Better enter in 80s in Chicago hospitals than now Now, form an alliance with suppliers or buyers to bargain or compete with sub/comp and other hospitals In 80s, differentiate to avoid sub/comp

15. Template – Internal Rivalry CurrentFuture Degree of seller concentration? Rate of industry growth? Significant cost differences among firms? Excess capacity? Cost structure of firms: sensitivity of costs to capacity utilization? Degree of product differentiation among sellers? Brand loyalty to existing sellers? Cross-price elasticities of demand among competitors in industry? Buyers’ switching costs?

16. Template – Internal Rivalry CurrentFuture Are prices and terms of sales transactions observable? Can firms adjust prices quickly? Large and/or infrequent sales orders? Use of ”facilitating practices”? History of “cooperative” pricing? Strength of exit barriers?

17. Template – Threat of Entry CurrentFuture Significant economies of scale Importance of reputation or established brand loyalties in purchase decision Entrants’ access to distribution channels Entrants’ access to raw materials Entrants’ access to technology/know-how Entrants’ access to favorable locations Experience-based advantages of incumbents

18. Template – Threat of Entry CurrentFuture Network externalities Government protection of incumbents Perception of entrants about expected retaliation of incumbents/reputations of incumbents for ‘toughness’

19. Template – Substitutes & Complements CurrentFuture Availability of close substitutes Price-value characteristics of substitutes Price elasticity of industry demand Availability of close complements Price-value characteristics of complements

20. Template – Suppliers CurrentFuture Is supplier industry more concentrated than industry it sells to? Do firms in industry purchase small volumes relative to other customers of suppliers? Is typical firm’s purchase volume small relative to sales of typical suppliers? Few substitutes for suppliers’ input Do firms in industry make relationship-specific investments to support transactions with specific suppliers? Do suppliers pose credible threat of forward integration into the product market? Are suppliers able to price-discriminate among prospective customers according to ability/willingness to pay for input?

21. Template – Buyers CurrentFuture Is buyers’ industry more concentrated than industry it purchases from? Do buyers purchase in large volumes? Does a buyer’s purchase volume represent large fraction of typical seller’s sales revenue? Can buyers find substitutes for industry’s product? Do firms in industry make relationship-specific investments to support transactions with specific buyers? Is price elasticity of demand of buyer’s product high?

22. Template – Buyers CurrentFuture Do buyers pose credible threat of backward integration? Does product represent significant fraction of cost in buyer’s business? Are prices in the market negotiated between buyers’ and sellers on each individual transaction or do sellers post a ‘take it or leave it’ price that applies to all transaction?