Patient choice and provider competition – Quality enhancing drivers in primary care?

Examining patient choice and provider competition under the National Health Insurance Fund outpatient cover in Kenya: does it enhance access and quality of care?

BACKGROUND

While patient choice and provider competition are predicted to influence provider behaviour for enhancing access and quality of care, evidence on provider perceptions and response to patient choice and provider competition is largely missing in low-resource settings such as Kenya. We examined provider and purchaser perceptions about whether patient choice and provider competition influenced provider behaviour and enhanced access and quality of outpatient care in Kenya.

METHODS

We conducted a qualitative study to explore this across two purposefully selected counties. We conducted 15 in-depth interviews (IDIs) with health facility managers and National Health Insurance Fund (NHIF) staff across the two counties. We examined these across five areas summarised as either local market conditions or patient feedback following the Vengberg framework.

RESULTS

NHIF members' choice of outpatient facilities compelled private and faith-based providers to compete for members while public providers did not view choice as a way of spurring competition. Besides, all providers did not receive any information regarding the exit of NHIF members from their facilities. Providers felt that that information would be crucial for their planning, especially in enhancing service accessibility and quality of care. Most providers ensured the availability of drugs, provided a wider range of services and leveraged on marketing to attract and retain NHIF members. Finally, providers highlighted their redesign of service delivery to meet NHIF members' needs whilst enhancing the quality-of-care aspects such as waiting time and having qualified health workers.

CONCLUSION

There is a need for NHIF to share NHIF members' exit information with providers to support their service delivery arrangements in response to NHIF members' needs. Besides, this study contributes evidence on patient choice and provider competition and their influence on access and quality of care from a low-resource setting country which is crucial as NHIF transitioned to the Social Health Authority.

Hospital competition and health outcomes: Evidence from acute myocardial infarction admissions in Germany

Countries increasingly rely on competition among hospitals to improve health outcomes. However, there is limited empirical evidence on the effect of competition on health outcomes in Germany. We examined the effect of hospital competition on quality of care, which is assessed using health outcomes (risk-adjusted in-hospital and post-hospitalization mortality and cardiac-related readmissions), focusing on acute myocardial infarction (AMI) treatment. We obtained data on all hospital utilizations and mortality of 13.2% of the population from a large statutory health insurer and all AMI admission records from Diagnosis-Related Groups Statistic from 2015-19. We constructed the measures of hospital competition, which mitigates the possibility of endogeneity bias. The relationships between health outcomes and competition measures are estimated using linear probability models. Intense competition was associated with lower quality of care in terms of mortality and cardiac-related readmissions. Patients treated in hospitals facing high competition were 0.9 (1.2) percentage points more likely to die within 90 days (2 years) of admission, and 1.4 (1.6) percentage points more likely to be readmitted within 90 days (2 years) of discharge than patients treated in hospitals facing low competition. Our results indicate that hospital competition does not lead to better health outcomes for AMI patients in Germany. Therefore, additional measures are necessary to achieve quality improvement.

Heterogeneous effects of hospital competition on inpatient quality: an analysis of five common diseases in China

BACKGROUND

Many countries has introduced pro-competition policies in the delivery of healthcare to improve medical quality, including China. With the increasing intensity of competition in China's healthcare market, there are rising concerns among policymakers about the impact of hospital competition on quality. This study investigated heterogeneous effects of hospital competition on inpatient quality.

METHODS

We analyzed the inpatient discharge dataset and selected chronic obstructive pulmonary disease (COPD), ischemic stroke, pneumonia, hemorrhagic stroke, and acute myocardial infarction (AMI) as representative diseases. A total of 561,429 patients in Sichuan Province in 2017 and 2019 were included. The outcomes of interest were in-hospital mortality and 30-day unplanned readmissions. The Herfindahl-Hirschman Index was calculated using predicted patient flows to measure hospital competition. To address the spatial correlations of hospitals and the structure of the dataset, the multiple membership multiple classification model was employed for analysis.

RESULTS

Amid intensifying competition in the hospital market, our study discerned no marked statistical variance in the risk of inpatient quality across most diseases examined. Amplified competition exhibited a positive correlation with heightened in-hospital mortality for both COPD and pneumonia patients. Elevated competition escalated the risk of 30-day unplanned readmissions for COPD patients, while inversely affecting the risk for AMI patients.

CONCLUSIONS

There is the heterogeneous impact of hospital competition on quality across various diseases in China. Policymakers who intend to leverage hospital competition as a tool to enhance healthcare quality must be cognizant of the possible influences of it.

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

BACKGROUND

Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES

We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN

With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS

A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES

Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.

RESULTS

Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS

After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Assessing the choice of National Health Insurance Fund contracted outpatient facilities in Kenya: A qualitative study

OBJECTIVE

To assess National Health Insurance Fund (NHIF) members' level of understanding, experiences, and factors influencing their choice of NHIF-contracted outpatient facilities in Kenya.

METHODS

We conducted a cross-sectional qualitative study with NHIF members in two purposefully selected counties (Nyeri and Makueni counties) in Kenya. We collected data through 15 focus group discussions with NHIF members. Data were analysed using a framework analysis approach.

RESULTS

Urban-based NHIF members had a good understanding of the NHIF-contracted outpatient facility selection process and the approaches for choosing and changing providers, unlike their rural counterparts. While NHIF members were required to choose a provider before accessing care, the number of available alternative facilities was perceived to be inadequate. Finally, NHIF members identified seven factors they considered important when choosing an NHIF-contracted outpatient provider. Of these factors, the availability of drugs, distance from the household to the facility and waiting time at the facility until consultation were considered the most important.

CONCLUSION

There is a need for the NHIF to prioritise awareness-raising approaches tailored to rural settings. Further, there is a need for the NHIF to contract more providers to both spur competition among providers and provide alternatives for members to choose from. Besides, NHIF members revealed the important factors they consider when selecting outpatient facilities. Consequently, NHIF should leverage the preferred factors when contracting healthcare providers. Similarly, healthcare providers should enhance the availability of drugs, reduce waiting times whilst improving their staff's attitudes which would improve user satisfaction and the quality of care provided.

A systematic review of the accessibility, acceptability, safety, efficiency, clinical effectiveness, and cost-effectiveness of private cataract and orthopedic surgery clinics

OBJECTIVES

Many publicly funded health systems use a mix of privately and publicly operated providers of care to deliver elective surgical services. The aim of this systematic review was to assess the role of privately operated but publicly funded provision of surgical services for adult patients who had cataract or orthopedic surgery within publicly funded health systems in high-income countries.

METHODS

Electronic databases (Ovid MEDLINE, OVID Embase, and EBSCO EconLit) were searched on 26 March 2021, and gray literature sources were searched on 6 April 2021. Two reviewers independently applied inclusion and exclusion criteria to identify studies, and extracted data. The outcomes evaluated include accessibility, acceptability, safety, clinical effectiveness, efficiency, and cost/cost-effectiveness.

RESULTS

Twenty-nine primary studies met the inclusion criteria and were synthesized narratively. We found mixed results across each of our reported outcomes. Wait times were shorter for patients treated in private facilities. There was evidence that some private facilities cherry-pick or cream-skim by selecting less complex patients, which increases the postoperative length of stay and costs for public facilities, restricts access to private facilities for certain groups of patients, and increases inequality within the health system. Seven studies found improved safety outcomes in private facilities, noting that private patients had a lower preoperative risk of complications. Only two studies reported cost and cost-effectiveness outcomes. One costing study concluded that private facilities' costs were lower than those of public facilities, and a cost-utility study showed that private contracting to reduce public waiting times for joint replacement was cost-effective.

CONCLUSIONS

Limited evidence exists that private-sector contracts address existing healthcare delivery problems. Value for money also remains to be evaluated properly.

Exploring differences between public and private providers in primary care: findings from a large Swedish region

This study contributes to the sparse literature on differences between public and private primary care practices (PCCs). The purpose was to explore if differences in performance and characteristics between public and PCCs persist over time in a welfare market with patient choice and provider competition, where public and private providers operate under similar conditions. The analysis is based on data from a national patient survey and administrative registries in a large Swedish region, covering PCC observations in 2010 and 2019, i.e., the year after and 10 years after introducing choice and competition in the region. The findings suggest that differences across owner types tend to decrease over time in welfare markets. Differences in patients' experiences, PCC size, patient mix and the division of labour have decreased or disappeared between 2010 and 2019. There were small but significant differences in process measures of quality in 2019; public PCCs complied better with prescription guidelines. While the results demonstrate a convergence between public and private PCCs in regards to their characteristics and performance, differences in patients' experiences in regards to socioeconomic conditions persisted. Such unwarranted variation calls for continued attention from policy makers and further research about causes.

Influence of E-consultation on Intention of First-visit Patients to Select Medical Services: Based on a Scenario Survey (Preprint)

BACKGROUND

E-consultation is expected to improve the information level of patients, affect patients' subsequent judgments of medical services, and guide patients to make a reasonable medical selection in the future. Thus, it is important to understand the influence mechanism of e-consultation on patients' medical selection.

OBJECTIVE

This study aims to explore the changes in first-visit patients' understanding of disease and medical resources after e-consultation as well as the choice of follow-up medical services.

METHODS

Patients' medical selection before and after e-consultation was compared using a scenario survey. Based on the service characteristics of the e-consultation platform, representative simulation scenarios were determined, and parallel control groups were set up considering the order effect in comparison. Finally, a total of 4 scenario simulation questionnaires were designed. A total of 4164 valid questionnaires were collected through the online questionnaire collection platform. Patients' perception of disease severity, evaluation of treatment capacity of medical institutions, selection of hospitals and doctors, and other outcome indicators were tested to analyze the differences in patients' evaluation and choice of medical services before and after e-consultation. Additionally, the results' stability was tested by regression analysis.

RESULTS

In scenario 1 (mild case), before e-consultation, 14.1% (104/740) of participants considered their conditions as not serious. After e-consultation, 69.5% (539/775) of them considered their diseases as not serious. Furthermore, participants' evaluation of the disease treatment capacity of medical institutions at all levels had improved after using e-consultation. In scenario 3 (severe case), before e-consultation, 54.1% (494/913) of the participants believed their diseases were very serious. After e-consultation, 16.6% (157/945) considered their diseases were very serious. The evaluation of disease treatment capacity of medical institutions in nontertiary hospitals decreased, whereas that of tertiary hospitals improved. In both mild and severe cases, before e-consultation, all of the participants were inclined to directly visit the hospital. After e-consultation, more than 71.4% (553/775) of the patients with mild diseases chose self-treatment, whereas those with severe diseases still opted for a face-to-face consultation. After e-consultation, patients who were set on being treated in a hospital, regardless of the disease severity, preferred to select the tertiary hospitals. Of the patients with mild diseases who chose to go to a hospital, 25.7% (57/222) wanted to consult online doctors face-to-face. By contrast, 56.4% (506/897) of the severe cases wanted to consult online doctors face-to-face.

CONCLUSIONS

E-consultation can help patients accurately enhance their awareness of the disease and guide them to make a more reasonable medical selection. However, it is likely that e-consultation makes online medical services centralized. Additionally, the guiding effect of e-consultation is limited, and e-consultation needs to be combined with other supporting systems conducive to medical selection to play an improved role.

A transition of power in opioid substitution treatment: Clinic managers' views on the consequences of a patient choice reform

Objectives: Opioid substitution treatment (OST) is often described as a strict and highly regulated treatment method, in which patients have limited influence over their treatment. In 2014, a reform was introduced by the regional council of Skåne in southern Sweden, which allowed OST patients to choose their treatment provider, thus transferring power from care providers to patients. The aim of this study was to examine what this increase in patient influence has meant for the clinics that provide OST in Skåne, and how these clinics have dealt with the new competitive situation that has arisen following the introduction of the reform. Methods: The study is based on two waves of semi-structured interviews with clinic managers at all OST clinics in Skåne. Results: The clinic managers described the increase in patient influence as a positive change, which had led to the patients being treated with more respect. The competition among clinics was expressed, among other things, in the form of differing views on the prescription of benzodiazepines, which initially gave rise to dissatisfaction among clinics with a more restrictive approach to such prescriptions. The reform did not lead to any clear diversity between clinics, apart from different approaches to the prescription of benzodiazepines. The incentive for competition-based diversity is, however, limited by the strict national regulatory system and by the reimbursement system, which restricts the ways in which clinics can conduct treatment activities. Conclusion: OST-clinic managers were largely positive about the increased patient empowerment and the shift in power balance associated with the patient choice reform. The introduction of the reform did not lead to any clear diversity between treatment providers, apart from differing views on the prescription of benzodiazepines, which by some managers was regarded as unfair competition.

Fifteen years with patient choice and free establishment in Swedish primary healthcare: what do we know?

Background:

In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.

Aim:

The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.

Methods:

A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included.

Results:

The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.

Conclusions:

The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.

From loyalty to resignation: Patient-doctor figurations in type 1 diabetes

This paper contributes to the debate on the patient-doctor relationship by focussing on a specific chronic disease: type 1 diabetes. This field is characterised by an increasing use of technology, specifically therapeutic devices and a significant requirement of patient self-management. This paper presents the main findings of research conducted in Italy in 2018. It is argued that this relationship is more properly described as an interdependent figuration of actors characterised by a dynamic process of power balances, which recalls Elias' (What is sociology? Columbia University Press, 1978) figurational-processual and relational sociology. In this theoretical context, patients may manage their (dis)satisfaction with their diabetologists by choosing different behaviours that stem from Hirschman's archetype (Exit, voice, and loyalty. Responses to decline firms, organizations, and states. Harvard University Press, 1970): voice, exit, loyalty and, we would add, resignation. These categories are fluid, and all of them can be experienced by patients over time, depending on the quality of the figurations built among these transactors.

Assessing competition in the hip implant industry in the light of recent policy guidance

NHS procurement is a highly topical area, attracting a great deal of recent policy focus. The pivotal report by Lord Carter of Coles (2016) highlighted unwarranted variation, estimating it to be worth approximately £5bn in efficiency savings. In relation to hip replacement surgery, recent procurement policy guidance has recommended the use of cemented hip implants for all patients aged 68 years and over in England and Wales. Previous work established that the hip implant supplying market was very concentrated, with only a few large suppliers, especially for cemented implants. The advocated major shift towards cemented implants would almost certainly increase further the market share of the dominant manufacturer of cemented sector thus raising potential competition and welfare issues. We carry out a market study to establish whether there might be a potential competition concern, using data from the National Joint Registry (2005-2018, 37 suppliers, nearly 700 models). We first establish the structure of the industry with a specific focus on seller concentration. Secondly we evaluate the dynamics underlying concentration in the market, assessing the innovative performance of the sector using a novel statistical analysis of the dynamics of market shares. We then look to three comparable but alternative markets for similarities or differences to the THR implant industry. We find a high and increasingly concentrated oligopolistic and static market structure, largely devoid of dynamics and with no real sign of innovation. These findings are further emphasized when compared with the three close alternative markets. Although this stability could just be a mature market where technical advances have already taken place, our findings highlight the potential welfare and policy implications of concentrating on cemented fixation. Given the current emphasis on efficiency in procurement, it is essential that there should also be scrutiny of the firms dealing with public procurement.

Patients' perceptions of quality in Swedish primary care - a study of differences between private and public ownership

Purpose

The purpose of the paper is to describe and analyze differences in patients' quality perceptions of private and public primary care centers in Sweden.

Design/methodology/approach

The article explores the differences in quality perceptions between patients of public and private primary care centers based on data from a large patient survey in Sweden. The survey covers seven dimensions, and in this paper the measure Overall impression was used for the comparison. With more than 80,000 valid responses, the survey covers all primary care centers in Sweden which allowed for a detailed analysis of differences in quality perceptions among patients from the different categories of owners.

Findings

The article contributes with a detailed description of different types of private owners: not-for-profit and for profit, as well as corporate groups and independent care centers. The results show a higher quality perception for independent centers compared to both public and corporate groups.

Research limitations/implications

The small number of not-for-profit centers (21 out of 1,117 centers) does not allow for clear conclusions for this group. The results, however, indicate an even higher patient quality perception for not-for-profit centers. The study focus on describing differences in quality perceptions between the owner categories. Future research can contribute with explanations to why independent care centers receive higher patient satisfaction.

Social implications

The results from the study have policy implications both in a Swedish as well as international perspective. The differentiation between different types of private owners made in this paper opens up for interesting discussions on privatization of healthcare and how it affects patient satisfaction.

Originality/value

The main contribution of the paper is the detailed comparison of different categories of private owners and the public owners.

Money matters - primary care providers' perceptions of payment incentives

PURPOSE

Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work.

DESIGN/METHODOLOGY/APPROACH

An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system.

FINDINGS

Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses.

PRACTICAL IMPLICATIONS

Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers.

ORIGINALITY/VALUE

This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms

Policies aiming to spur quality competition among health care providers are ubiquitous, but their impact on quality is ex ante ambiguous, and credible empirical evidence is lacking in many contexts. This study contributes to the sparse literature on competition and primary care quality by examining recent competition enhancing reforms in Sweden. The reforms aimed to stimulate patient choice and entry of private providers across the country but affected markets differently depending on the initial market structure. We exploit the heterogeneous impact of the reforms in a difference-in-differences strategy, contrasting more and less exposed markets over the period 2005-2013. Although the reforms led to substantially more entry of new providers in more exposed markets, the effects on primary care quality were modest: We find small improvements of patients' overall satisfaction with care, but no consistently significant effects on avoidable hospitalisation rates or satisfaction with access to care. We find no evidence of economically meaningful quality reductions on any outcome measure.