ABSTRACT
Institutional theory research on institutional intermediation typically focuses on how institutional intermediaries address voids in market-based institutions that inhibit entrepreneurship. In doing so, the research rarely studies what types of institutional intermediaries entrepreneurs prefer to use. We address this gap with a microinstitutional inquiry of how entrepreneurs in a rudimentary market-based economy differ in the relevance they place on different types of institutional intermediaries. Using a sample from the Indrachok market in Kathmandu, Nepal, and using a three-stage qualitative and quantitative abductive investigation of a cascading set of increasingly refined research questions, we identify two key preferences for institutional intermediaries. First, we find a key institutional intermediation tripod consisting of three locally focused institutional intermediaries: family, suppliers, and peer entrepreneurs. The tripod is supplemented by institutional intermediaries with more moderate preference in this context: four other locally focused institutional intermediaries (local politicians, police, religious figures, and political gangs) and three broad-based institutional intermediaries (government, microlenders, and nongovernmental organizations). Second, the importance of suppliers and peers as institutional intermediaries reflects entrepreneurs' registration status (registered versus unregistered) and microgeographic location (dispersed versus clustered businesses). The research reconceptualizes institutional intermediation in rudimentary market-based economies from the entrepreneurs' perspective, identifying mechanisms that shape entrepreneurs' preferences and providing proposition for future testing.
ABSTRACT
Billing and insurance-related costs are a significant source of wasteful health care spending in Organization for Economic Cooperation and Development nations, but these administrative burdens vary across national systems. We executed a microlevel accounting of these costs in different national settings at six provider locations in five nations (Australia, Canada, Germany, the Netherlands, and Singapore) that supplements our prior study measuring the costs in the US. We found that billing and insurance-related costs for inpatient bills range from a low of $6 in Canada to a high of $215 in the US for an inpatient surgical bill (purchasing power parity adjusted). We created a taxonomy of billing and insurance-related activities (eligibility, coding, submission, and rework) that was applied to data from the six sites and allows cross-national comparisons. Higher costs in the US and Australia are attributed to high coding costs. Much of the savings achieved in some nations is attributable to assigning tasks to people in lower-skill job categories, although most of the savings are due to more efficient billing and insurance-related processes. Some nations also reduce these costs by offering financial counseling to patients before treatment. Our microlevel approach can identify specific cost drivers and reveal national billing features that reduce coding costs. It illustrates a valuable pathway for future research in understanding and mitigating administrative costs in health care.