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Lindaas NA, Anthun KS, Magnussen J. New Public Management and hospital efficiency: the case of Norwegian public hospital trusts. BMC Health Serv Res 2024; 24:36. [PMID: 38183065 PMCID: PMC10770877 DOI: 10.1186/s12913-023-10479-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/14/2023] [Indexed: 01/07/2024] Open
Abstract
New Public Management-inspired reforms in the Norwegian hospital sector have introduced several features from the private sector into a predominantly public healthcare system. Since the late 1990s, several reforms have been carried out with the intention of improving the utilization of resources. There is, however, limited knowledge about the long-term, and sector-wide effects of these reforms. In this study, using a panel data set of all public hospital trusts spanning nine years, we provide an analysis of the efficiency of hospital trusts using data envelopment analysis (DEA), as well as a Malmquist productivity index. Thereafter we use the efficiency scores as the dependent variable in a second-stage panel data regression analysis. We show that during the period between 2011 and 2019, on average, efficiency has increased over time. Further, in the second-stage analysis, we show that New Public Management features related to incentivization are associated with the level of hospital efficiency. We find no association between degree of competition and efficiency.
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Affiliation(s)
- Nils Arne Lindaas
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491, Trondheim, P.O. Box 8905, Norway.
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491, Trondheim, P.O. Box 8905, Norway
- Department of Health Research, SINTEF Digital, 7465, Torgaarden, Trondheim, P.O. Box 4760, Norway
| | - Jon Magnussen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491, Trondheim, P.O. Box 8905, Norway
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2
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Bosque-Mercader L, Siciliani L. The association between bed occupancy rates and hospital quality in the English National Health Service. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:209-236. [PMID: 35579804 PMCID: PMC9112248 DOI: 10.1007/s10198-022-01464-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 04/05/2022] [Indexed: 05/14/2023]
Abstract
We study whether hospitals that exhibit systematically higher bed occupancy rates are associated with lower quality in England over 2010/11-2017/18. We develop an economic conceptual framework to guide our empirical analysis and run regressions to inform possible policy interventions. First, we run a pooled OLS regression to test if high bed occupancy is associated with, and therefore acts as a signal of, lower quality, which could trigger additional regulation. Second, we test whether this association is explained by exogenous demand-supply factors such as potential demand, and unavoidable costs. Third, we include determinants of bed occupancy (beds, length of stay, and volume) that might be associated with quality directly, rather than indirectly through bed occupancy. Last, we use a within-between random-effects specification to decompose these associations into those due to variations in characteristics between hospitals and variations within hospitals. We find that bed occupancy rates are positively associated with overall and surgical mortality, negatively associated with patient-reported health gains, but not associated with other indicators. These results are robust to controlling for demand-supply shifters, beds, and volume. The associations reduce by 12%-25% after controlling for length of stay in most cases and are explained by variations in bed occupancy between hospitals.
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Affiliation(s)
- Laia Bosque-Mercader
- Department of Economics and Related Studies, University of York, York, YO10 5DD, UK.
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, YO10 5DD, UK
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3
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Dohmen P, van Ineveld M, Markus A, van der Hagen L, van de Klundert J. Does competition improve hospital performance: a DEA based evaluation from the Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022:1-19. [PMID: 36192512 PMCID: PMC9529606 DOI: 10.1007/s10198-022-01529-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
Many countries have introduced competition among hospitals aiming to improve their performance. We evaluate the introduction of competition among hospitals in the Netherlands over the years 2008-2015. The analysis is based on a unique longitudinal data set covering all Dutch hospitals and health insurers, as well as demographic and geographic data. We measure hospital performance using Data Envelopment Analysis and distinguish three components of competition: the fraction of freely negotiated services, market power of hospitals, and insurer bargaining power. We present new methods to define variables for each of these components which are more accurate than previously developed measures. In a multivariate regression analysis, the variables explain more than half of the variance in hospital efficiency. The results indicate that competition between hospitals and the relative fraction of freely negotiable health services are positively related to hospital efficiency. At the same time, the policy measure to steadily increase the fraction of health services contracted in competition may well have resulted in a decrease in hospital efficiency. The models show no significant association between insurer bargaining power and hospital efficiency. Altogether, the results offer little evidence that the introduction of competition for hospital care in the Netherlands has been effective.
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Affiliation(s)
- Peter Dohmen
- Rotterdam School of Management, Erasmus University, Rotterdam, The Netherlands.
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
- Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa), Utrecht, The Netherlands.
| | - Martin van Ineveld
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Aniek Markus
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Liana van der Hagen
- Rotterdam School of Management, Erasmus University, Rotterdam, The Netherlands
| | - Joris van de Klundert
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- School of Business, Universidad Adolfo Ibanez, Santiago de Chile, Chile
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4
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Lu L, Lin X, Pan J. Heterogeneous effects of hospital competition on inpatient expenses: an empirical analysis of diseases grouping basing on conditions' complexity and urgency. BMC Health Serv Res 2021; 21:1322. [PMID: 34893077 PMCID: PMC8662870 DOI: 10.1186/s12913-021-07331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/24/2021] [Indexed: 11/13/2022] Open
Abstract
Background
Multiple pro-competition policies were implemented during the new round of healthcare reform in China. Differences in conditions’ complexity and urgency across diseases associating with various degrees of information asymmetry and choice autonomy in the process of care provision, would lead to heterogeneous effects of competition on healthcare expenses. However, there are limited studies to explore it. This study aims to examine the heterogeneous effects of hospital competition on inpatient expenses basing on disease grouping according to conditions’ complexity and urgency. Methods Collecting information from discharge data of inpatients and hospital administrative data of Sichuan province in China, we selected representative diseases. K-means clustering was used to group the selected diseases and Herfindahl-Hirschman Index (HHI) was calculated based on the predicted patient flow to measure the hospital competition. The log-linear multivariate regression model was used to examine the heterogeneous effects of hospital competition on inpatient expenses. Results We selected 19 representative diseases with significant burdens (more than 1.1 million hospitalizations). The selected diseases were divided into three groups, including diseases with highly complex conditions, diseases with urgent conditions, and diseases with less complex and less urgent conditions. For diseases with highly complex conditions and diseases with urgent conditions, the estimated coefficients of HHI are mixed in the direction and statistical significance in the identical regression model at the 5% level. For diseases with less complex and less urgent conditions, the coefficients of HHI are all positive, and almost all of them significant at the 5% level. Conclusions We found heterogeneous effects of hospital competition on inpatient expenses across disease groups: hospital competition does not play an ideal role in reducing inpatient expenses for diseases with highly complex conditions and diseases with urgent conditions, but it has a significant effect in reducing inpatient expenses of diseases with less complex and less urgent conditions. Our study offers implications that the differences in condition’s complexity and urgency among diseases would lead to different impacts of hospital competition, which would be given full consideration when designing the pro-competition policy in the healthcare delivery system to achieve the desired goal. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07331-1.
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Affiliation(s)
- Liyong Lu
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041, Sichuan, China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Xiaojun Lin
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041, Sichuan, China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3, Ren Min Nan Road, Chengdu, 610041, Sichuan, China. .,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China.
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5
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Zhou T, Yang Y, Hu M, Jian W, Pan J. Director's Perceived Competition and Its Relationship with Hospital's Competitive Behaviors: Evidence from County Hospitals in China. Risk Manag Healthc Policy 2021; 14:4113-4125. [PMID: 34629916 PMCID: PMC8493273 DOI: 10.2147/rmhp.s328807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/14/2021] [Indexed: 01/24/2023] Open
Abstract
Background This study was conducted for assessing the degrees of perceived competition reported by county hospital directors in rural China as well as hospitals’ competitive behaviors in response to competition. Methods The data were collected from Analysis of Provider Payment Reforms on Advancing China’s Health (APPROACH) project which had been implemented among county hospitals in China’s Guizhou province. Competition was measured by asking hospital directors to rate the levels of competitive pressure as they perceived. Hospitals’ competitive behaviors were obtained by asking hospitals’ directors about specific strategies they had adopted. A multivariable linear regression model was developed to examine the relationship between perceived competition and the positivity of competitive behavior, and multivariable logistic regressions were used to evaluate the influence of perceived competition on the adoption of specific competitive strategies. Results Among 218 directors engaged in this study, 210 (96.3%) directors reported the perception of certain degrees of competition, for which the competitive pressure was mainly posed by public hospitals (42.4%). Director-perceived competition level was found to be positively associated with the positivity of competitive behavior, and directors under higher competitive pressure were found to be more likely to adopt multiple competitive strategies including improving the efficiency of hospitals’ internal management, optimizing hospitals’ environment as well as promoting health-care services. Conclusion This study suggested that almost all of the county hospital directors in rural China perceived certain degrees of competitive pressure, and higher levels of perceived competition were found to be significantly associated with increased positivity in adopting competitive strategies. Our findings are expected to provide evidence-based implications for the implementation of a series of pro-competition policies throughout health-care reforms.
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Affiliation(s)
- Tingting Zhou
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| | - Yili Yang
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
| | - Min Hu
- School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, People's Republic of China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People's Republic of China
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6
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Jiang Q, Tian F, Liu Z, Pan J. Hospital Competition and Unplanned Readmission: Evidence from a Systematic Review. Risk Manag Healthc Policy 2021; 14:473-489. [PMID: 33574721 PMCID: PMC7873024 DOI: 10.2147/rmhp.s290643] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/01/2021] [Indexed: 11/23/2022] Open
Abstract
Competition has been widely introduced among hospitals in the hope of improving health-care quality. However, whether competition leads to higher-quality health care is a topic of considerable debate. We conducted a systematic review to assess the impact of hospital-market competition on unplanned readmission. We searched six electronic databases (PubMed, EmBase, Wiley Online Library, Web of Science, Scopus, and JSTOR) and reference lists of screened articles for relevant studies, and strictly followed methods proposed by the Cochrane Collaboration. Finally, nine observational studies with 2,241,767 patients were included. For the primary outcome, pooled results of three studies showed that it was uncertain whether or not hospital competition reduces readmission (β=0.02, P=0.06; very low certainty of evidence, as they were all observational studies with high heterogeneity). Inconsistent results were found in the remaining six studies, and they were assessed as very low–certainty evidence, downgraded for either inconsistency or indirectness or both. As for secondary outcomes, seven of the nine studies reported on the impact of competition on the risk of mortality, and two reported on length of stay (LOS). It was uncertain whether competition had an effect on mortality or LOS. The relevant studies were limited and of very low certainty, which means there is currently no reliable evidence showing that hospital competition reduces quality of health care in terms of readmission/mortality/LOS. There is a need for rigorous studies to assess the impact of hospital competition on the quality of health care.
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Affiliation(s)
- Qingling Jiang
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fan Tian
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Zhenmi Liu
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.,Department of Maternal, Child and Adolescent Health, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jay Pan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.,Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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7
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Walsh B, Lyons S, Smith S, Wren MA, Eighan J, Morgenroth E. Does formal home care reduce inpatient length of stay? HEALTH ECONOMICS 2020; 29:1620-1636. [PMID: 32924255 DOI: 10.1002/hec.4158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/03/2020] [Accepted: 08/18/2020] [Indexed: 06/11/2023]
Abstract
Formal home care is an appropriate substitute for acute hospital care for many older people. However, limited empirical evidence exists on the extent of substitution between the supply of home care and hospital use. This study examines whether patients from areas with a better supply of home care have lower inpatient length of stay (LOS). We link administrative data on over 300,000 public hospital inpatient admissions in Ireland between 2012 and 2015 to region-year panel data on public home care supply. In addition to modeling average LOS, we estimate unconditional quantile regressions to examine whether home care supply has a disproportionately strong impact on long LOS. We find that inpatients from areas with higher per capita home care supply have lower average LOS; a 10% increase in home care is associated with a 1.2%-2.1% reduction in LOS. This result is driven by the subset of patients with the longest LOS, likely delayed discharges. Stronger results were found for stroke and hip fracture patients, who might be expected to have higher than average propensity to use home care services, and for patients from a region that experienced an unusually large increase in home care supply.
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Affiliation(s)
- Brendan Walsh
- Economic and Social Research Institute, Dublin, Ireland
- Department of Economics, Trinity College Dublin, Dublin, Ireland
| | - Seán Lyons
- Economic and Social Research Institute, Dublin, Ireland
- Department of Economics, Trinity College Dublin, Dublin, Ireland
| | - Samantha Smith
- Centre for Health Policy & Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maev-Ann Wren
- Economic and Social Research Institute, Dublin, Ireland
- Department of Economics, Trinity College Dublin, Dublin, Ireland
| | - James Eighan
- Economic and Social Research Institute, Dublin, Ireland
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Gaughan J, Siciliani L, Gravelle H, Moscelli G. Do small hospitals have lower quality? Evidence from the English NHS. Soc Sci Med 2020; 265:113500. [PMID: 33221070 PMCID: PMC7768184 DOI: 10.1016/j.socscimed.2020.113500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/28/2020] [Accepted: 11/01/2020] [Indexed: 11/17/2022]
Abstract
We investigate the extent to which small hospitals are associated with lower quality. We first take a patient perspective, and test if, controlling for casemix, patients admitted to small hospitals receive lower quality than those admitted to larger hospitals. We then investigate if differences in quality between large and small hospitals can be explained by hospital characteristics such as hospital type and staffing. We use a range of quality measures including hospital mortality rates (overall and for specific conditions), hospital acquired infection rates, waiting times for emergency patients, and patient perceptions of the care they receive. We find that small hospitals, with fewer than 400 beds, are generally not associated with lower quality before or after controlling for hospital characteristics. The only exception is heart attack mortality, which is generally higher in small hospitals.
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Affiliation(s)
- James Gaughan
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, YO10 5DD, UK.
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Giuseppe Moscelli
- Department of Economics, University of Surrey, Guildford, Surrey, GU2 7XH, UK
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9
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Jiang Q, Pan J. The Evolving Hospital Market in China After the 2009 Healthcare Reform. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020968783. [PMID: 33124476 PMCID: PMC7607735 DOI: 10.1177/0046958020968783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Since the initiation of national healthcare reform in 2009, China’s hospital market has witnessed significant change. To provide a brief description about its evolving process, China Health Statistical Yearbook data and Sichuan administrative data from 2009 to 2017 were used in this article. An overall upward trend of hospital delivery capacity was found in this study, which increased from 3.12 million beds and 1.09 million doctors in 2009 to 6.12 million and 1.80 million in 2017, respectively, while the primary healthcare institutions presented fairly slow development pace. Growing proportion of medical resources and patients gathered in hospitals, especially tertiary hospitals. While private hospitals demonstrated an increasingly important role in hospital market with growing share of capacity and service, their average capacity, especially the human resource, was found to be much lower than that of public hospitals and the gaps are still widening. The competition among hospitals grouped by homogeneous ownership types has predominated the increasingly intensified hospital market competition in China. In order to adapt to the raising demand of health care in China, it is highly recommended that strategies forged at governmental levels be focused on primary care promotion, guiding the development of private hospitals as well as on promoting orderly competition in the hospital market.
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Affiliation(s)
- Qingling Jiang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.,Institite for Healthy Cities, Sichuan University, Chengdu, China
| | - Jay Pan
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.,Institite for Healthy Cities, Sichuan University, Chengdu, China
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10
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Cellini R, Lisi D. Readmission treatment price and product quality in the hospital sector. HEALTH ECONOMICS 2020; 29:61-71. [PMID: 31856381 DOI: 10.1002/hec.3966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 06/10/2023]
Abstract
In this paper, we study the effect of readmission treatment payment in a dynamic framework characterised by competition among hospitals and sluggish beliefs of patients concerning the service quality. We find that the effect of readmission treatment payment depends on the interplay between the effect of quality in lowering readmissions and its effect on future demand. When the readmission occurrence strongly depends on the service quality, the higher the readmission treatment payment for hospitals, the lower the incentive to provide quality. Instead, when readmission depends barely on quality, the readmission payment acts as the treatment price for first admissions, and thus it reinforces the incentive to provide quality. We also show that the detrimental effect of readmission payments on quality are fed by a high degree of demand sluggishness, that is, by situation where current quality has modest effect on future demand changes. Our findings are robust to different equilibrium concepts of the differential game (i.e., open-loop and state-feedback). The results suggest that a discounted regulated price for readmission can be an effective (and cost-free) policy tool to improve health care quality, especially when the market is characterised by sluggish beliefs about quality.
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Affiliation(s)
- Roberto Cellini
- Department of Economics and Business, University of Catania, Catania, Italy
| | - Domenico Lisi
- Department of Economics and Business, University of Catania, Catania, Italy
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