The bureaucratic barriers to launching a primary care practice

For years, as insurance premiums climbed and Americans worried about medical expenses , economists have pointed to industry concentration as one cause.

That policy conversation, however, usually focuses on how today’s competitors exit the market, through hospital mergers or medical practice buyouts. It neglects the other side of the competition question: whether new providers are able to join the fray or bring innovative service models to patients.

Over the past four years, I helped build a new primary care practice in California, Nevada, and Arizona. We mostly care for elderly people, usually in their homes.

As we’ve expanded, our practice has confronted one reason that health care markets are so slow to change and often so uncompetitive. In nearly all the places that we operate,