Market strategies used by private hospital providers to consolidate and increase power; a systematic scoping review and evaluative synthesis

Hospitals controlled by private firms, like many private sectors, will employ market strategies to safeguard their investments and increase the profitability of the services they provide. These market strategies not only determine their financial success but also influences broader outcomes, including health system performance and population health indicators. Yet, strategies that enhance market influence and profitability may at times diverge from those aimed at improving health outcomes. This raises issues around market power imbalances and concerns that hospitals could prioritise profits over health if forced to choose. This systematic scoping review sought to identify and synthesise scholarly evidence on the market strategies employed by private hospitals to expand and consolidate market power. Titles and abstracts of 1,642 English-language articles sourced from seven databases were screened, with 371 articles assessed for eligibility based on whether they identified the use of market strategies within a hospital setting. Data from 133 relevant studies were extracted and analysed thematically using Porter’s ‘Five Forces’ framework. We identified 22 distinct market strategies used by private hospitals, falling under six interconnected strategic objectives: 1) reduce rivalry among existing competitors; 2) raise barriers to market entry by new competitors; 3) counter the threat of market disruptors and drive patient health service usage towards hospital care provided by the hospital; 4) increase hospital buyer power by exerting leverage over upstream actors; 5) Increase hospital seller power by exerting leverage over downstream organisational actors; and 6) increase hospital seller power by exerting leverage over downstream individual actors. Although international in scope, the United States accounted for over two-thirds of the studies included. This partly reflects the dominance of U.S. scholarship in these areas. The resulting typological framework offers a structured means of analysing hospital market strategies internationally, within and across jurisdictions. Additionally, it can aid the identification of pertinent public policies, such as those addressing merger control, unfair trading practices, and public procurement. This works to bolster policy-analytic functions that can be influential in rectifying market-power imbalances.