Information asymmetry and performance tilting in hospitals: a national empirical study

Does patient behaviour drive physicians to practice defensive medicine? Evidence from a video experiment

OBJECTIVE

By manipulating patients' critical attitude in a video experiment, we examined whether physicians are more intended to perform defensive acts because of a higher perceived liability risk in Belgium.

METHODS

We assigned 85 practicing gynaecologists/obstetricians and orthopaedists randomly to four hypothetical video consultations, in which the patients show either a critical attitude (i.e., getting ahead of the facts, showing distrust) or a non-critical attitude (i.e., displaying more neutral questions and expressions). We asked the physicians about the care they would administer in the presented cases and the expected likelihood that the patient would sue the physician in case of a medical incident.

RESULTS

By manipulating patients' verbal critical attitude (which indicates patients' intention to take further steps), while keeping constant physician's communication, patients' clinical situation, preferences, and non-verbal behaviour in the videos, we were able to discover differential treatment styles driven by physicians' perceived liability risk among patients with a different critical attitude. We found that physicians perform 17 percentage points more defensive acts (e.g., surgeries and diagnostic tests that are not medically necessary) when experiencing a high liability risk.

CONCLUSIONS

Our results show that patients' critical attitude drives physicians' perceived liability risk and consequent defensive behaviour among obstetricians/gynaecologists and orthopaedists.

"The reputation premium": does hospital ranking improvement lead to a higher healthcare spending?

Global health systems have often disclosed hospital quality and performance information via hospital ranking or rating programs over the last 20 years. This study aims to examine the relationship between hospital ranking and healthcare spending. Using the Basic Medical Insurance claims data from a big city in central China and the hospital ranking data from the Fudan Chinese Hospital League Table from 2016 to 2018, this study exploits the variation of hospital reputable ranking across hospitals and periods to employ the difference-in-differences (DiD) design. To alleviate the self-selection bias emerging from inpatients' selection of hospitals and the extrapolation bias emerging from the potential mis-specification of our linear model, we combine the DiD design with the 3-to-1 optimal Mahalanobis metric matching method. This study finds that ceteris paribus one hospital ascending from the Regional Famous Hospital Group to the National Famous Hospital Group significantly increases inpatients' total healthcare costs, reimbursement costs, and out-of-pocket costs by 5.9%, 6.2%, and 4.0%, respectively. Mechanism analysis reveals that it should be attributed more to physician moral hazard than patient willingness-to-pay. Leads and lags (event study) analysis validates our DiD identification framework and shows that the impact materializes slowly but significantly. In the robustness check, we transfer the outcome variables from the log value to the level value and control five digits of ICD-10 for the disease fixed-effects. The results are highly robust.

A Research Based on Online Medical Platform: The Influence of Strong and Weak Ties Information on Patients’ Consultation Behavior

As an indispensable part of contemporary medical services, Internet-based medical platforms can provide patients with a full range of multi-disciplinary and multi-modal treatment services. Along with the emergence of many healthcare influencers and the increasing connection between online and offline consultations, the operation of individual physicians and their teams on Internet-based medical platforms has started to attract a lot of attention. The purpose of this paper is to, based on an Internet platform, study how the information on physicians’ homepages influences patients’ consultation behavior, so as to provide suggestions for the construction of physicians’ personal websites. We distinguish variables into strong- and weak-ties types, dependent on whether deep social interactions between physicians and patients have happened. If there exist further social interactions, we define the variable as the “strong ties” type, otherwise, “weak ties”. The patients’ consultation behavior will be expressed as the volume of online consultation, i.e., the number of patients. We obtained the strong and weak ties information of each physician based on EWM (entropy weight method), so as to establish a regression model with explained variable, i.e., the number of patients, and three explanatory variables, i.e., the strong and weak ties information, and their interaction term. The estimation results verified our hypotheses and proved to be robust. It showed that both strong and weak ties information can positively influence patients’ consultation behavior, and the influence of weak ties information is greater. Regarding the positive influence of strong and weak ties, we found a trade off effect between them. Based on the results, we finalize with some suggestions on how to improve a physician’s online medical consultation volume.

The Equity of Health Care Spending in South Korea: Testing the Impact of Publicness

This paper examined the important organizational and managerial factors of publicness for the equity of health care. The extent of organizational publicness was measured with key independent variables such as ownership, evaluation, and accreditation. The dependent variable was measured by three equity indicators for patients under medical care and veterans care: financial inequity, social equity, and overall equity. We analyzed unbalanced panel data with 328 general hospitals between 2008 and 2012. We performed panel analysis with fixed and random effects. Our findings illustrate that government ownership is significantly associated with differences in equity indicators. Government owned hospitals show the better performance for equity than nonprofit and individually owned hospitals do. Compared to nonprofit and individually owned hospitals, government owned hospitals have a higher share of medical payment bills and health care spending for the disadvantaged but a lower proportion of out-of-pocket payment. Government evaluation is also significantly related to better equity performance. There are, however, significantly negative interactions between hospital government ownership and the size of medical payment bills. We found a significant tendency that the more medical payments, the less responsiveness to the equity of health care in government owned hospitals. Future research in hospital performance is required to consider not only sectoral differences but also the negative proclivity of public hospitals that shrink health care services for the poor. Further research is also expected to explore what sectoral identities and behaviors across public, nonprofit, and private hospitals influence the level of equity or inequity in health care.

Determinants of utilization and out-of-pocket payments for psychiatric healthcare in Iran

Purpose

Mental health is an inevitable and vital dimension when it comes to providing a global definition for the appropriate health status. This highlights the importance of investigating factors influencing utilization and out-of-pocket payments (OOP) for mental health services. Thus, the purpose of this paper is to assess the determinants of the utilization and OOP for psychiatric healthcare in Iran.

Design/methodology/approach

A total of 39,864 households were included in this cross-sectional study. Data on the utilization and OOP for psychiatric healthcare as well as all their determinants (e.g. wealth index of households, geographical area, household size, etc.) were extracted from the Household Income and Expenditure Survey (HIES). The HIES was conducted by the Statistical Center of Iran in 2016. A zero-inflated Tobit model was used to identify the main factors affecting utilization and OOP for psychiatric healthcare utilization.

Findings

The average of utilization and OOP for psychiatric services was found to be 14.67 times per 1,000 households and $7.783 per month for service users, respectively. There were significant positive relationships between income and utilization (p=0.0002) and OOP (p<0.0001) for psychiatric services. Significant negative associations were found between the number of illiterate people in the household and OOP (coefficient=−1.56) and utilization (coefficient=−0.2002) for psychiatric services. Utilization and OOP for psychiatric services were statistically significantly higher among households with higher wealth status.

Originality/value

Despite the higher rate of mental disorders, the utilization of psychiatric services in Iran is very low. Due to financial barriers and insufficient insurance coverage, high socioeconomic status (SES) households utilize more psychiatric services than low-SES households. Thus, the integration of mental health services in public health programs is required to improve the utilization of psychiatric services in Iran.

Do All Hospital Systems Have Market Power? Association Between Hospital System Types and Cardiac Surgery Prices

OBJECTIVE

This study explores the price implications of hospital systems by analyzing the association of system characteristics with selected cardiac surgery pricing.

DATA SOURCE

Using a large private insurance claim database, the authors identified 11 282 coronary artery bypass graft (CABG) cases and 49 866 percutaneous coronary intervention (PCI) cases from 2002 to 2007.

STUDY DESIGN

We conducted a retrospective observational study using generalized linear models.

PRINCIPAL FINDINGS

We found that the CABG and PCI prices in centralized health and physician insurance systems were significantly lower than the prices in stand-alone hospitals by 4.4% and 6.4%, respectively. In addition, the CABG and PCI prices in independent health systems were significantly lower than in stand-alone hospitals, by 15.4% and 14.5%, respectively.

CONCLUSION

The current antitrust guidelines tend to focus on the market share of merging parties and pay less attention to the characteristics of merging parties. The results of this study suggest that antitrust analysis could be more effective by considering characteristics of hospital systems.

Ambulance transport to the emergency department: A patient-selected signal of acuity and its effect on resource provision

OBJECTIVE

To determine whether ambulance arrival to the emergency department has remained an unidentified signal of perceived medical acuity. Informed by economic signaling theory, does arrival via ambulance affect resource utilization given varying levels of patient acuity?

METHODS

The analysis examined a nationally representative sample of de-identified emergency department patient encounters from 2011 to 2015, gathered from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Multivariate logistic regression analysis was employed using regional and time-fixed effects. The provision of twenty diagnostic and imaging services was analyzed. Patient encounters were also categorized into five acuity-levels.

RESULTS

Drawing from the NHAMCS dataset, 98,888 emergency department records were analyzed, weighted to represent 504.5 million estimated emergency department patient encounters. Findings suggest that patients transported to the hospital via ambulance are more likely than those who arrive by other means to receive 19 of the 20 analyzed diagnostic testing and imaging services. Furthermore, when analyzed by acuity-level, the disparity of service provision is the greatest among low-acuity patients, where medical complaints are argued to be the most subjective.

CONCLUSIONS

The results are consistent with the notion that emergency department medical providers readily accept ambulance transport as a valid signal of patient acuity, regardless of true acuity level. Consequently, patients transported to the hospital via ambulance may be receiving a disproportionate amount of medical resources in an increasingly cost-conscious environment.

The economic burden of mental disorders in China, 2005-2013: implications for health policy

BACKGROUND

Mental disorders represent a major contributor to disease burden worldwide. We sought to quantify the national economic burden of mental disorders in China.

METHODS

We used a prevalence-based, bottom-up approach to estimate the economic costs of mental disorders in 2005-2013 in China. Prevalence data were derived from a national survey. Cost data were derived from the electronic health records of two psychiatric hospitals that consisted of 25,289 outpatients (10%) and inpatients (90%) who were diagnosed with a mental disorder. Cost items included direct medical costs, direct non-medical costs, and indirect costs.

RESULTS

The total annual costs of mental disorders in China increased from $1,094.8 in 2005 to $3,665.4 in 2013 for individual patients, and from $21.0 billion to $88.8 billion for the whole society. The total costs of mental disorders in 2013 accounted for more than 15% of the total health expenditure in China, and 1.1% of China's gross domestic product. If the needs of the professional care for all patients with mental illnesses were fully met, the potential economic costs would have been almost five times higher than the actual estimated costs.

CONCLUSIONS

Mental disorders imposed a huge economic burden on individuals and the society in China. A nation-wide strategic action plan for preventing mental disorders and promoting mental health and well-being is in urgent need to reduce the individual and societal costs of mental illnesses.

Attitudes toward inter-hospital electronic patient record exchange: discrepancies among physicians, medical record staff, and patients

Background

In this era of ubiquitous information, patient record exchange among hospitals still has technological and individual barriers including resistance to information sharing. Most research on user attitudes has been limited to one type of user or aspect. Because few analyses of attitudes toward electronic patient records (EPRs) have been conducted, understanding the attitudes among different users in multiple aspects is crucial to user acceptance. This proof-of-concept study investigated the attitudes of users toward the inter-hospital EPR exchange system implemented nationwide and focused on discrepant behavioral intentions among three user groups.

Methods

The system was designed by combining a Health Level 7-based protocol, object-relational mapping, and other medical informatics techniques to ensure interoperability in realizing patient-centered practices. After implementation, three user-specific questionnaires for physicians, medical record staff, and patients were administered, with a 70 % response rate. The instrument showed favorable convergent construct validity and internal consistency reliability. Two dependent variables were applied: the attitudes toward privacy and support. Independent variables comprised personal characteristics, work characteristics, human aspects, and technology aspects. Major statistical methods included exploratory factor analysis and general linear model.

Results

The results from 379 respondents indicated that the patients highly agreed with privacy protection by their consent and support for EPRs, whereas the physicians remained conservative toward both. Medical record staff was ranked in the middle among the three groups. The three user groups demonstrated discrepant intentions toward privacy protection and support. Experience of computer use, level of concerns, usefulness of functions, and specifically, reason to use electronic medical records and number of outpatient visits were significantly associated with the perceptions. Overall, four categories of independent variables were associated with the mean difference in the perceptions.

Conclusions

Discrepant attitudes toward privacy and support among the three user groups are identified. Patients may require further education and communication regarding the system. Culturally fit e-Consent should be incorporated into the system to fully utilize the computing power of the Internet when also considering workload. The concern for misuse of EPRs might lead to low support among physicians. Highly readable EPR documents and managerial incentives for information exchange may improve system use.

Disparities in the use of preventive health care among children with disabilities in Taiwan

Children with disabilities face more barriers accessing preventive health services. Prior research has documented disparities in the receipt of these services. However, most are limited to specific types of disability or care. This study investigates disparities in the use of preventive health care among children with disabilities in Taiwan. Three nationwide databases from the Ministry of the Interior, Bureau of Health Promotion, and National Health Research Institutes were linked to gather related information between 2006 and 2008. A total of 8572 children with disabilities aged 1-7 years were included in this study. Multivariate logistic regression analysis was conducted to adjust for covariates. Nationally, only 37.58% of children with disabilities received preventive health care in 2008. Children with severe and very severe disabilities were less likely to use preventive care than those with mild severity. Children with disabilities from the lowest income family were less likely to have preventive care than other income groups. Urbanization was strongly associated with the receipt of preventive health care. However, surprisingly, urban children with disabilities were less likely to receive preventive care than all others. Under universal health insurance coverage, the overall usage of preventive health care is still low among children with disabilities. The study also identified several disparities in their usage. Potential factors affecting the lack of use deserve additional research. Policymakers should target low socioeconomic brackets and foster education about the importance of preventive care. Mobile health services should be continually provided in those areas in need. Capitation reimbursement and other incentives should be considered in improving the utilization among children with disabilities.