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Yang G, Zhang X, Xu Z, Zhang L. Social Medical Insurances, Choices of Medical Institutions and the 'Siphon Effect' in the Health Service Market: Evidence from 2021 Yangtze River Delta Region of China. Risk Manag Healthc Policy 2024; 17:1287-1299. [PMID: 38770148 PMCID: PMC11104391 DOI: 10.2147/rmhp.s458178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose The siphon effect in the health service market is notably pronounced in many countries. How to measure and identify the determinants contributing to the siphon effect presents a substantial challenge. This study aimed to analyse the effect of two different social medical insurances, the Basic Medical Insurance System for Urban Employees (BMISUE), and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR), on the siphon effect in the health services market. Methods The data used in this study were from the 2021 Health Life Satisfaction Survey of Yangtze River Delta (HLSSYRD) conducted by Shanghai Jiao Tong University. The logistic model was used to evaluate the association between social medical insurances and individual choices of medical institutions, and the Propensity Score Matching method (PSM) was used to check the robustness of basic results. Results Residents covered by BMISUE were more likely to choose a general hospital when they first sought medical treatment (OR = 5.377, 95% CI: 4.887, 5.915) relative to those insured by BMISURR. Further analysis showed that BMISUE would accelerate the siphon effect of general hospitals, people insured by BMISUE were still more likely to choose general hospitals despite being close to primary hospitals compared to those insured by BMISURR (OR = 3.240, 95% CI: 2.945, 3.565). Heterogeneity analysis indicated BMISUE had a greater impact on residents aged 15-59 years and those with high income compared to older people and individuals with low income. Conclusion Different social medical insurances can substantially affect residents' first choice of medical institutions. BMISUE with higher benefits level could exacerbate the siphon effect in the health service market. More equitable medical security system should be strengthened to bridge the benefits gap between BMISUE and BMISURR.
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Affiliation(s)
- Guang Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Xiaodong Zhang
- Institute of Population Research, Peking University, Beijing, People’s Republic of China
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
| | - Zhaopeng Xu
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Lufa Zhang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
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2
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Scott A, Taylor T, Russell G, Sutton M. Associations between corporate ownership of primary care providers and doctor wellbeing, workload, access, organizational efficiency, and service quality. Health Policy 2024; 142:105028. [PMID: 38387240 DOI: 10.1016/j.healthpol.2024.105028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 12/15/2023] [Accepted: 02/17/2024] [Indexed: 02/24/2024]
Abstract
Traditionally, in many countries general practices have been privately-owned independent small businesses. However, the last three decades has seen the rise of large corporate medical groups defined as private companies which are able to have non-GP shareholders and with branches across many locations. The greater prominence of profit motives may have implications for costs, access to care and quality of care. We estimate that 45% of GPs in Australia worked in a practice that was a private company, and within this group over one third (19.9% of total) worked in a corporate medical group (a private company with 10 or more practice locations). We examine the association between being in a corporate medical group and 19 outcomes classified into five groups: GP wellbeing, workload, patient access, organizational efficiency, and service quality. GPs who worked in such groups were more likely to be older, qualified overseas, and to have a conscientious personality. There was mixed evidence on GPs wellbeing, with GPs in corporate medical groups reporting a higher turnover of GPs but similar levels of job satisfaction. GP workload was similar in terms of hours worked and after hours work but they reported a lower work-life balance. Patient access was better in terms of lower fees charged to patients but there was weak evidence that patients waited longer. GPs in corporate medical groups reported higher organisational efficiency because GPs spent less time spent on administration and management, had more nurses per GP, but despite this GPs were more likely to undertake tasks someone less qualified could do suggesting that nurses were complements not substitutes. There were no differences in service quality (teaching, patient complaints, consultation length, patients seen per hour). Corporate medical groups have become a substantial part of primary care provision in Australia. There is evidence they are more efficient, patient access is better with lower out of pocket costs and there are no differences in our measures service quality, but concerns remain about GP's wellbeing and work-life balance. Further research is needed on continuity of care and patient reported experiences and health outcomes.
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Affiliation(s)
- Anthony Scott
- Centre for Health Economics, Monash Business School, Monash University, Building H, Level 5, Caulfield East, Australia.
| | | | - Grant Russell
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Australia
| | - Matt Sutton
- Centre for Health Economics, Monash Business School, Monash University, Building H, Level 5, Caulfield East, Australia; Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, United Kingdom
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3
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Olinger R, Matejka B, Chakravarty R, Johnston M, Ornelas E, Draves J, Jain N, Hentschel J, Owen W, Ma Y, Marx W, Freitag J, Zhang N, Guage C, Crabtree C. Americans do not select their doctors based on race. FRONTIERS IN SOCIOLOGY 2024; 8:1191080. [PMID: 38328739 PMCID: PMC10847235 DOI: 10.3389/fsoc.2023.1191080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/28/2023] [Indexed: 02/09/2024]
Abstract
To what extent do Americans racially discriminate against doctors? While a large literature shows that racial biases pervade the American healthcare system, there has been no systematic examination of these biases in terms of who patients select for medical treatment. We examine this question in the context of the ongoing global COVID-19 pandemic, where a wealth of qualitative evidence suggests that discrimination against some historically marginalized communities, particularly Asians, has increased throughout the United States. Conducting a well-powered conjoint experiment with a national sample of 1,498 Americans, we find that respondents do not, on average, discriminate against Asian or doctors from other systematically minoritized groups. We also find no consistent evidence of treatment effect heterogeneity; Americans of all types appear not to care about the racial identity of their doctor, at least in our study. This finding has important implications for the potential limits of American prejudice.
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4
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Ballart X, Rico G. How much convergence exists between registered process measures and patient reported experience measures? A study on Catalan primary healthcare. Int J Health Plann Manage 2023; 38:1772-1788. [PMID: 37653581 DOI: 10.1002/hpm.3701] [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: 01/11/2023] [Revised: 07/22/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023] Open
Abstract
The use of quality measures is important for transparency and the continuous improvement of performance. However, we do not know enough about the relationship between registered process measures and patient reported experience measures (PREMs) in primary healthcare. Recent studies point to areas of convergence that run contrary anticipated trends. This is a relevant question for healthcare management and governments as their position is stronger when system's guidelines and targets also matter to patients or, vice versa, when patient-centered measures are used to develop new process measures. Our aim is to study both type of measures, their logic and their level of convergence. We also assess the relationship between PREMs, patients' demographic characteristics and area socioeconomic level. We estimated pairwise correlations with patient experience aggregated at the health-center level and a series of multilevel regression models to assess the adjusted effect of four registered process measures on ratings of patient experience at the patient level. We use patient experience as measured by survey data, two composite quality indices and two single indicators regularly computed by the Catalan Health Service. Continuity of care with the same doctor and accessibility are positively associated with patient experience. No relationship was observed in the index created to measure quality of assistance. The index measuring the quality of prescriptions was positively associated with patient experience but only when analyzed separately. We conclude that registered process measures and PREMs are not entirely independent, hence improvements of the management side have the potential to impact patient experience.
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Affiliation(s)
- Xavier Ballart
- Departament de Ciència Política, Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Guillem Rico
- Departament de Ciència Política, Universitat Autonoma de Barcelona, Bellaterra, Spain
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5
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Hayes H, Meacock R, Stokes J, Sutton M. How do family doctors respond to reduced waiting times for cancer diagnosis in secondary care? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023:10.1007/s10198-023-01626-2. [PMID: 37787842 DOI: 10.1007/s10198-023-01626-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 08/09/2023] [Indexed: 10/04/2023]
Abstract
Reducing waiting times is a priority in public health systems. Efforts of healthcare providers to shorten waiting times could be negated if they simultaneously induce substantial increases in demand. However, separating out the effects of changes in supply and demand on waiting times requires an exogenous change in one element. We examine the impact of a pilot programme in some English hospitals to shorten waiting times for urgent diagnosis of suspected cancer on family doctors' referrals. We examine referrals from 6,666 family doctor partnerships to 145 hospitals between 1st April 2012 and 31st March 2019. Five hospitals piloted shorter waiting times initiatives in 2017. Using continuous difference-in-differences regression, we exploit the pilot as a 'supply shifter' to estimate the effect of waiting times on referral volumes for two suspected cancer types: bowel and lung. The proportion of referred patients breaching two-week waiting times targets for suspected bowel cancer fell by 3.9 percentage points in pilot hospitals in response to the policy, from a baseline of 4.8%. Family doctors exposed to the pilot increased their referrals (demand) by 10.8%. However, the pilot was not successful for lung cancer, with some evidence that waiting times increased, and a corresponding reduction in referrals of -10.5%. Family doctor referrals for suspected cancer are responsive at the margin to waiting times. Healthcare providers may struggle to achieve long-term reductions in waiting times if supply-side improvements are offset by increases in demand.
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Affiliation(s)
- Helen Hayes
- Office of Health Economics (OHE), London, UK.
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK.
| | - Rachel Meacock
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Jonathan Stokes
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
- MRC/CSO Social & Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
- Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, The University of Melbourne, Parkville, VIC, Australia
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6
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Brosig-Koch J, Hehenkamp B, Kokot J. Who benefits from quality competition in health care? A theory and a laboratory experiment on the relevance of patient characteristics. HEALTH ECONOMICS 2023. [PMID: 37147773 DOI: 10.1002/hec.4689] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 03/27/2023] [Accepted: 04/06/2023] [Indexed: 05/07/2023]
Abstract
We study how competition between physicians affects the provision of medical care. In our theoretical model, physicians are faced with a heterogeneous patient population, in which patients systematically vary with regard to both their responsiveness to the provided quality of care and their state of health. We test the behavioral predictions derived from this model in a controlled laboratory experiment. In line with the model, we observe that competition significantly improves patient benefits as long as patients are able to respond to the quality provided. For those patients, who are not able to choose a physician, competition even decreases the patient benefit compared to a situation without competition. This decrease is in contrast to our theoretical prediction implying no change in benefits for passive patients. Deviations from patient-optimal treatment are highest for passive patients in need of a low quantity of medical services. With repetition, both, the positive effects of competition for active patients as well as the negative effects of competition for passive patients become more pronounced. Our results imply that competition can not only improve but also worsen patient outcome and that patients' responsiveness to quality is decisive.
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Affiliation(s)
- Jeannette Brosig-Koch
- Otto von Guericke University Magdeburg and Health Economics Research Center (CINCH) Essen, Magdeburg, Germany
| | | | - Johanna Kokot
- University of Hamburg, Hamburg Center for Health Economics (HCHE), Hamburg, Germany
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7
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Ferré F, Seghieri C, Nuti S. Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications. Health Policy 2023; 131:104781. [PMID: 36963172 DOI: 10.1016/j.healthpol.2023.104781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 02/24/2023] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Abstract
This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.
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Affiliation(s)
- Francesca Ferré
- Laboratorio Management e Sanità, Istituto di Management Dipartimento EMbeDS Scuola Superiore Sant'Anna of Pisa, Italy.
| | - Chiara Seghieri
- Laboratorio Management e Sanità, Istituto di Management Dipartimento EMbeDS Scuola Superiore Sant'Anna of Pisa, Italy
| | - Sabina Nuti
- Health Science Interdisciplinary Research Centre, Scuola Superiore Sant'Anna of Pisa, Italy
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8
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Allanson P, Cookson R. Comparing healthcare quality: A common framework for both ordinal and cardinal data with an application to primary care variation in England. HEALTH ECONOMICS 2022; 31:2593-2608. [PMID: 36030529 PMCID: PMC9804671 DOI: 10.1002/hec.4597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/28/2022] [Accepted: 08/13/2022] [Indexed: 06/15/2023]
Abstract
The paper proposes a framework for comparing the quality of healthcare providers and assessing the variation in quality between them, which is directly applicable to both ordinal and cardinal quality data on a comparable basis. The resultant measures are sensitive to the full distribution of quality scores for each provider, not just the mean or the proportion meeting some binary quality threshold, thereby making full use of the multicategory response data increasingly available from patient experience surveys. The measures can also be standardized for factors such as age, sex, ethnicity, health and deprivation using a distribution regression model. We illustrate by measuring the quality of primary care services in England in 2019 using three different sources of publicly available, general practice-level information: multicategory response patient experience data, ordinal inspection ratings and cardinal clinical achievement scores. We find considerable variation at both local and regional levels using all three data sources. However, the correlation between the comparative quality indices calculated using the alternative data sources is weak, suggesting that they capture different aspects of general practice quality.
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9
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FERNÁNDEZ-PÉREZ ÁNGEL, JIMÉNEZ-RUBIO DOLORES, ROBONE SILVANA. Freedom of choice and health services’ performance: Evidence from a National Health System. Health Policy 2022; 126:1283-1290. [DOI: 10.1016/j.healthpol.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/11/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022]
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10
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Liu J, Ma Z, Su J, Ge B. Optimal information disclosure strategy in the primary healthcare service market: From the perspective of signaling theory. Front Public Health 2022; 10:959032. [PMID: 36388347 PMCID: PMC9650283 DOI: 10.3389/fpubh.2022.959032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/06/2022] [Indexed: 01/24/2023] Open
Abstract
The promotion of general practitioner (GP) contract service is one of the key components of China's healthcare reform. We consider GPs providing primary health services with private competency information over two periods, where patients decide when to sign. Two types of GPs are considered: those with higher and lower competency. Under asymmetric information, to spur the patients' incentive to sign, the GPs can move to offer competency disclosure schemes to patients, for example, separating or pooling, through which true competency information is revealed, respectively. We investigate three scenarios, which are referred to as "separating-separating," "pooling-separating," and "pooling-pooling." The results of the three scenarios yield intriguing insights into the impact of the GP's competency disclosure decisions. Findings include that GPs prefer the "pooling-separating" strategy, but patients prefer "separating-separating." Besides, an extremely low cure rate may enable GPs to conceal some competency information. Furthermore, low-competency GPs may exaggerate their competency level for profit, but greater efforts in disclosing competency information may result in diminished benefits. Therefore, to promote the services of GPs, the core is always to improve GPs' competency.
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11
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Lim KS, Yap WA, Yip W. Consumer choice and public-private providers: The role of perceived prices. HEALTH ECONOMICS 2022; 31:1898-1925. [PMID: 35661324 DOI: 10.1002/hec.4554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 12/04/2021] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Governments often encourage health service providers to improve quality of care and reduce prices through competition. The efficacy of competition hinges on the assumption that consumers demand high quality care at low prices for any given health condition. In this paper, we examine this assumption by investigating the role of perceived price and quality on consumer choice for four different health conditions across public and private providers. We use a nationally representative survey in Malaysia to elicit respondents' perception on prices and quality, and their preferred choice of provider. We estimate a mixed logit model and show that consumers value different dimensions of quality depending on the health condition. Furthermore, increasing perceived prices for private providers reduces demand for minor, more frequent health conditions such as flu fever or cough, but increases demand for more complex, severe conditions such as coronary artery bypass graft. These findings provide empirical support for price regulation which differentiates the severity of underlying health conditions.
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Affiliation(s)
- Kai Shen Lim
- Graduate School of Arts and Sciences, Harvard University, Boston, Massachusetts, USA
| | - Wei Aun Yap
- Quanticlear Solutions, Petaling Jaya, Malaysia
| | - Winnie Yip
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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12
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Scott A, Sivey P. Motivation and competition in health care. HEALTH ECONOMICS 2022; 31:1695-1712. [PMID: 35643938 PMCID: PMC9544404 DOI: 10.1002/hec.4533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 04/06/2022] [Accepted: 04/27/2022] [Indexed: 06/15/2023]
Abstract
Non-pecuniary sources of motivation are a strong feature of the health care sector and the impact of competitive incentives on behavior may be lower where pecuniary motivation is low. This paper measures the marginal utility of income (MUY) of physicians from a stated-choice experiment, and examines whether this measure influences the association between competition faced by physicians and the prices they charge. We find that physicians are more likely to exploit a lack of competition with higher prices if they have a high MUY.
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Affiliation(s)
- Anthony Scott
- Melbourne Institute: Applied Economic and Social ResearchThe University of MelbourneMelbourneVictoriaAustralia
| | - Peter Sivey
- Centre for Health EconomicsUniversity of YorkYorkUK
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Zhao X, Xiao J, Chen H, Lin K, Li X, Zeng Z, Huang S, Xie Z, Du J. Patient preferences and attitudes towards first choice medical services in Shenzhen, China: a cross-sectional study. BMJ Open 2022; 12:e057280. [PMID: 35613747 PMCID: PMC9174822 DOI: 10.1136/bmjopen-2021-057280] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study aimed to explore the characteristics of Shenzhen residents' preferences and influencing factors regarding their first choice of medical institution at various medical levels, and to understand their attitudes towards community health services. DESIGN Cross-sectional survey. PARTICIPANTS A total of 1612 participants at least 18 years of age were randomly sampled with stratification among 10 districts in Shenzhen. Data were gathered through a self-designed questionnaire. The effective questionnaire response rate was 93.05%. All patients participated in the study voluntarily, provided written informed consent and were able to complete the questionnaire. MAIN OUTCOME MEASURES We measured and compared the participants' expected and actual preferences and influencing factors regarding their first choice of medical service at various medical levels. RESULTS More than 50% of the participants preferred municipal and district hospitals as their first choice, and 27.5% chose medical institutions according to specific circumstances. Univariate analysis indicated that age, education, income, medical insurance, housing conditions and registered permanent residence were significantly associated with the actual and expected preferred first medical institution. The main factors influencing participants' actual and expected preferred medical institution differed. With the actual preferred first medical institution as the dependent variable, education, monthly income, medical technology, convenience and providers' service attitude and medical ethics were the main factors (χ2=212.63, p<0.001), whereas with the expected preferred first medical institution as the dependent variable, occupation, Shenzhen registered permanent residence, education and medical technology were the main factors (χ2=78.101, p<0.001). CONCLUSION The main factors influencing participants' preferred medical institution and their actual first visit differed. Patients with high education or income or registered permanent residence preferred high-level medical institutions for the first visit.
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Affiliation(s)
- Xinyu Zhao
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Junhui Xiao
- Institute of Health Law and Policy, Guangdong Medical University, Dongguan, Guangdong, China
| | - Huida Chen
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Kena Lin
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Xiaoman Li
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Zhiwen Zeng
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Shuyun Huang
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
| | - Zhikui Xie
- Shenzhen Administration Institute, Shenzhen, Guangdong, China
| | - Jinlin Du
- Department of Epidemiology and Statistics, School of Public Health, Guangdong Medical University, Dongguan, Guangdong, China
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14
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Gravelle H, Liu D, Santos R. How do clinical quality and patient satisfaction vary with provider size in primary care? Evidence from English general practice panel data. Soc Sci Med 2022; 301:114936. [PMID: 35367906 DOI: 10.1016/j.socscimed.2022.114936] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 11/26/2022]
Abstract
We examine the relationship between general practice list size and measures of clinical quality and patient satisfaction. Using data on all English practices from 2005/6 to 2016/17, we estimate practice level models with rich data on patient demographics, deprivation, and morbidity. We use lagged list size to allow for potential simultaneity bias from the effect of quality on list size. We compare results from three different estimation methods: pooled ordinary least squares, random practice effects, fixed practice effects. With all three estimation methods increased list size is associated with reductions in all four measures of patient satisfaction. Increases in list size are associated with worse performance on three clinical quality indicators and better performance on three, though the precision and size of the associations varies with the estimation method. The absolute values of the elasticities of the ten quality indicators with respect to list size are small: in all cases a 10% change in list size would change quality by less than 1%. The lack of evidence that large practices have markedly better quality suggests that encouraging practices to form larger, but looser, groupings, may not, in itself, improve their performance.
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Affiliation(s)
- Hugh Gravelle
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom.
| | - Dan Liu
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom; Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia.
| | - Rita Santos
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom.
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15
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Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, Blecher M, Cashin C, Esperato A, Hipgrave D, Kalisa I, Kurowski C, Meng Q, Morgan D, Mtei G, Nolte E, Onoka C, Powell-Jackson T, Roland M, Sadanandan R, Stenberg K, Vega Morales J, Wang H, Wurie H. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Health 2022; 10:e715-e772. [PMID: 35390342 PMCID: PMC9005653 DOI: 10.1016/s2214-109x(22)00005-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Nouria Brikci
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Darius Erlangga
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Abebe Alebachew
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Ina Kalisa
- World Health Organization, Kigali, Rwanda
| | | | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing, China
| | - David Morgan
- Health Division, The Organisation for Economic Co-operation and Development, Paris, France
| | | | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chima Onoka
- Department of Community Medicine, University of Nigeria, Enugu, Nigeria
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | | | | | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Simply the best? The impact of quality on choice of primary healthcare provider in Sweden. Health Policy 2021; 125:1448-1454. [PMID: 34645569 DOI: 10.1016/j.healthpol.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE One of the more important objectives with the patient choice reform, introducing non-price competition in Swedish primary healthcare, was to improve performance and quality of care. However, in order for choice to lead to quality improvements, citizens need to consider quality aspects in their choices of provider. We hypothesize that quality of care influences choice of provider and the objective of this study is to investigate if citizens are willing to make a trade-off between distance to chosen provider and quality of care. METHODS We use conditional logit models to analyse if quality and other provider attributes influence choice of provider. The study population includes all citizens of Region Stockholm with at least one primary healthcare contact (N ~1.4 million). RESULTS The results show that distance is the most important factor in choosing a primary healthcare provider but that there seems to be a willingness to make a trade-off between distance and quality measures. However, other provider attributes, such as the Care Need Index of the registered population, seem to influence choice to a greater extent than quality. CONCLUSION The results point in the same direction as the arguments behind the patient choice reform. However, the effects are marginal. To enhance quality competition, policy makers should consider making quality information at the provider level more accessible.
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Pitkänen V, Linnosmaa I. Choice, quality and patients' experience: evidence from a Finnish physiotherapy service. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2021; 21:229-245. [PMID: 33469804 PMCID: PMC8192355 DOI: 10.1007/s10754-020-09293-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 12/18/2020] [Indexed: 06/12/2023]
Abstract
We study the relationship between patient choices and provider quality in a rehabilitation service for disabled patients who receive the service frequently but do not have access to quality information. Previous research has found a positive relationship between patient choices and provider quality in health services that patients typically do not have previous experience or use frequently. We contribute by examining choices of new patients and experienced patients who were either forced to switch or actively switched their provider. In the analysis, we combine register data on patients' choices and switches with provider quality data from a competitive bidding, and estimate conditional logit choice models. The results show that all patients prefer high-quality providers within short distances. We find that the willingness to travel for quality is highest among new patients and active switchers. These results suggest that new patients and active switchers compare different alternatives more thoroughly, whereas forced switchers choose their new provider in limited time leading into poorer choices.
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Affiliation(s)
- Visa Pitkänen
- Research Department, Social Insurance Institution of Finland, P.O. Box 450, 00056, Helsinki, Finland.
| | - Ismo Linnosmaa
- Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Centre for Health and Social Economics, National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
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Kuklinski D, Vogel J, Geissler A. The impact of quality on hospital choice. Which information affects patients' behavior for colorectal resection or knee replacement? Health Care Manag Sci 2021; 24:185-202. [PMID: 33502719 PMCID: PMC8184721 DOI: 10.1007/s10729-020-09540-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/15/2020] [Indexed: 10/25/2022]
Abstract
Quality competition among hospitals, induced by patients freely choosing their hospital in a price regulated market, can only be realized if quality differences between hospitals are transparent, understandable, and thus influence patients' hospital choice. We use data from ~145,000 German patients and ~ 900 hospitals for colorectal resections and knee replacements to investigate whether patients value quality and specialization when choosing their hospital. Using a random utility choice model, we estimate patients' marginal utilities, willingness to travel and change in hospital demand for quality improvements. Patients respond to service quality and specialization and thus, quality competition seems to be present. Colorectal resection patients are willing to travel longer for more specialized hospitals (+9% for procedure volume, +9% for certification). Knee replacement patients travel longer for hospitals with better service quality (+6%) and higher procedure volume (+12%). However, clinical quality indicators, often difficult to access and interpret, barely play a role in patients' hospital choice. Furthermore, we find that competition on quality for colorectal resection is rather local, whereas for knee replacement we observe regional competition patterns.
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Affiliation(s)
- David Kuklinski
- Department of Health Care Management, Technische Universität Berlin, Strasse des 17. Juni 135, 10623 Berlin, Germany
| | - Justus Vogel
- Department of Health Care Management, Technische Universität Berlin, Strasse des 17. Juni 135, 10623 Berlin, Germany
| | - Alexander Geissler
- School of Medicine, University of St. Gallen, St. Jakob-Strasse 21, 9000 St. Gallen, Switzerland
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19
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Bensnes S, Huitfeldt I. Rumor has it: How do patients respond to patient-generated physician ratings? JOURNAL OF HEALTH ECONOMICS 2021; 76:102415. [PMID: 33422733 DOI: 10.1016/j.jhealeco.2020.102415] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/30/2020] [Accepted: 12/10/2020] [Indexed: 06/12/2023]
Abstract
This paper studies the impact of patient-generated ratings of primary care physicians in Norway. Norway has a universal health care system, with no available objective quality indicators. In May 2012, an online review platform that allows patients to rate their physician was launched. Relying on a difference-in-differences approach we show that higher-rated physicians see an increase in demand relative to lower-rated physicians. The effect is primarily driven by females and patients with high socioeconomic status. We find no indications that physicians change their practice style or supply of patient capacity in response to the ratings.
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Affiliation(s)
- Simon Bensnes
- Statistics Norway, Statistisk Sentralbyrå PB 2633 St. Hanshaugen, 0131 Oslo, Norway.
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20
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Ahmed K, Hashim S, Khankhara M, Said I, Shandakumar AT, Zaman S, Veiga A. What drives general practitioners in the UK to improve the quality of care? A systematic literature review. BMJ Open Qual 2021; 10:e001127. [PMID: 33574115 PMCID: PMC7880106 DOI: 10.1136/bmjoq-2020-001127] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated. OBJECTIVES (1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature. METHODS This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes. RESULTS 35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition. DISCUSSION The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care. CONCLUSION Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.
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Affiliation(s)
- Kanwal Ahmed
- School of Medicine, Imperial College London, London, London, UK
| | - Salma Hashim
- School of Medicine, Imperial College London, London, London, UK
| | | | - Ilhan Said
- School of Medicine, Imperial College London, London, London, UK
| | | | - Sadia Zaman
- School of Medicine, Imperial College London, London, London, UK
| | - Andre Veiga
- Business School, Imperial College London, London, London, UK
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21
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Status and Factors Associated with Healthcare Choices among Older Adults and Children in an Urbanized County: A Cross-Sectional Study in Kunshan, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228697. [PMID: 33238555 PMCID: PMC7700310 DOI: 10.3390/ijerph17228697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/17/2020] [Accepted: 11/19/2020] [Indexed: 11/17/2022]
Abstract
As important unit for regional health planning, urbanized counties are facing challenges because of internal migrants and aging. This study took urbanized counties in China as cases and two key populations as objects to understand different populations' intentions of choosing corresponding health service resources and to provide support for resource allocation. A cross-sectional study was conducted in Kunshan, a highly urbanized county in China, in 2016, among older adults aged 60 or over and children aged 0-6. Multinomial logistics models were used to identify the factors associated with healthcare choices. In this study, we found that income, distance of the tertiary provider, and migrant status were not associated with choices of tertiary healthcare outside county for children, while parents' education level was. The responsiveness of the tertiary provider inside the county was lower than primary and secondary providers inside the county, while respondents were dissatisfied with the medical technology and medical facility for the tertiary inside the county compared to those of the tertiary provider outside the county. Significant differences existed in terms of the perception of different categories of institutions. To conclude, local governments should particularly seek to strengthen pediatric primary health services and improve the responsiveness of healthcare facilities to treat geriatric and pediatric diseases, which also bring significance to the developing countries in the process of urbanization.
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22
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Santos R, Rice N, Gravelle H. Patterns of emergency admissions for ambulatory care sensitive conditions: a spatial cross-sectional analysis of observational data. BMJ Open 2020; 10:e039910. [PMID: 33148755 PMCID: PMC7643517 DOI: 10.1136/bmjopen-2020-039910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the spatial and temporal patterns of English general practices' emergency admissions for Ambulatory Care Sensitive Conditions (ACSCs). DESIGN Observational study of practice level annual hospital emergency admissions data for ACSCs for all English practices from 2004-2017. PARTICIPANTS All patients with an emergency admission to a National Health Service hospital in England who were registered with an English general practice. MAIN OUTCOME MEASURE Practice level age and gender indirectly standardised ratios (ISARs) for emergency admissions for ACSC. RESULTS In 2017, 41.8% of the total variation in ISARs across practices was between the 207 Clinical Commissioning Groups (CCGs) (the administrative unit for general practices) and 58.2% was across practices within CCGs. ACSC ISARs increased by 4.7% between 2004 and 2017, while those for conditions incentivised by the Quality and Outcomes Framework (QOF) fell by 20%. Practice ISARs are persistent: practices with high rates in 2004 also had high rates in 2017. Standardising by deprivation as well as age and gender reduced the coefficient of variation of practice ISARs in 2017 by 22%. CONCLUSIONS There is persistent spatial pattern of emergency admissions for ACSC across England both within and across CCGs. We illustrate the reduction in ACSCs emergency admissions across the study period for conditions incentivised by the QOF but find that this was not accompanied by a reduction in variation in these admissions across practices. The observed spatial pattern persists when admission rates are standardised by deprivation. The persistence of spatial clusters of high emergency admissions for ACSCs within and across CCG boundaries suggests that policies to reduce potentially unwarranted variation should be targeted at practice level.
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Affiliation(s)
- Rita Santos
- Centre for Health Economics, University of York, York, North Yorkshire, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, North Yorkshire, UK
- Department of Economics and Related Studies, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, North Yorkshire, UK
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Competition between Public and Private Maternity Care Providers in France: Evidence on Market Segmentation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17217846. [PMID: 33114744 PMCID: PMC7662386 DOI: 10.3390/ijerph17217846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 11/17/2022]
Abstract
The purpose of this paper is to investigate the potential for segmentation in hospital markets, using the French case where private for-profit providers play an important role having nearly 25% of market shares, and where prices are regulated, leading to quality competition. Using a stylized economic model of hospital competition, we investigate the potential for displacement between vertically differentiated public and private providers, focusing on maternity units where user choice is central. Building over the model, we test the following three hypotheses. First, the number of public maternity units is likely to be much larger in less populated departments than in more populated ones. Second, as the number of public maternity units decreases, the profitability constraint should allow more private players into the market. Third, private units are closer substitutes to other private units than to public units. Building an exhaustive and nationwide data set on the activity of maternity services linked to detailed data at a hospital level, we use an event study framework, which exploits two sources of variation: (1) The variation over time in the number of maternity units and (2) the variation in users' choices. We find support for our hypotheses, indicating that segmentation is at work in these markets with asymmetrical effects between public and private sectors that need to be accounted for when deciding on public market entry or exit.
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24
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Epstein DS, Barton C, Mazza D, Woode ME, Mortimer D. Patient chosen gap payments in primary care: Predictions of patient acceptability, uptake and willingness to pay from a discrete choice experiment. Soc Sci Med 2020; 263:113284. [PMID: 32818851 DOI: 10.1016/j.socscimed.2020.113284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/10/2023]
Abstract
Compulsory co-payments limit access and may compromise quality in primary care. Patient Chosen Gap Payments (PCGPs) allow patients to specify a (voluntary) out-of-pocket contribution, creating an incentive for patient-centred care without the need for complex outcomes-based funding formulae. It is not yet known if widespread use of PCGP services is consistent with consumer preferences. We conducted a discrete choice experiment (DCE) in a sample of the adult Australian general population (n = 1457) during April 2019 to simulate patient choice between alternative primary care services and describe preferences for PCGP services. Participants also completed a supplementary valuation task in which participants reported their intended PCGP contribution for PCGP services. Finally, we conducted policy-simulations to predict market shares when PCGP clinics operate alongside the two existing models of primary care funding in Australia. Results suggest that patients prefer shorter wait time, longer consults, lower compulsory copayments, services with higher patient satisfaction ratings, choice of doctor and $0 suggested voluntary contribution for PCGP services. Policy-simulations suggest that high-quality PCGP services could obtain market share of up to 39% and voluntary contributions of up to $25.36 per service (95%CI: $10.24, $40.47), potentially adding $1.48 billion AUD in revenues and funding for primary care at no cost to government. Low-quality PCGP services are unlikely to capture significant market share and PCGP contributions were lowest for low-quality PCGP services ($12.12, 95%CI: $2.09, $26.34). Further field testing is recommended where (i) patients make consequential choices (e.g. real payments for simulated services), and (ii) dynamic effects on quality of care and utilisation can be observed; particularly in vulnerable populations. We conclude that PCGP services aligned with patient preferences could capture significant market share and substantially increase revenue to general practice.
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Affiliation(s)
- D S Epstein
- Department of General Practice, Monash University, Australia.
| | - C Barton
- Department of General Practice, Monash University, Australia
| | - D Mazza
- Department of General Practice, Monash University, Australia
| | - M E Woode
- Centre for Health Economics, Monash University, Australia
| | - D Mortimer
- Centre for Health Economics, Monash University, Australia
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Fu P, Wang Y, Liu S, Li J, Gao Q, Zhou C, Meng Q, Sylvia S. Analysing the preferences for family doctor contract services in rural China: a study using a discrete choice experiment. BMC FAMILY PRACTICE 2020; 21:148. [PMID: 32711467 PMCID: PMC7382837 DOI: 10.1186/s12875-020-01223-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/15/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preliminary evaluations have found that family doctor contract services (FDCSs) have significantly controlled medical expenses, better managed chronic diseases, and increased patient satisfaction and service compliance. In 2016, China proposed the establishment of a family doctor system to carry out contract services, but studies have found the uptake and utilization of these services to be limited. This study aimed to investigate rural residents' preferences for FDCSs from the perspective of the Chinese public. METHODS A discrete choice experiment (DCE) was performed to elicit the preferences for FDCSs among rural residents in China. Attributes and levels were established based on a literature review and qualitative methods. Five attributes, i.e., cost, medicine availability, the reimbursement rate, family doctor competence, and family doctor attitude, were evaluated using a mixed logit model. RESULTS A total of 609 residents were included in the main DCE analysis. The respondents valued the high competence (coefficient 2.44, [SE 0.13]) and the good attitude (coefficient 1.42, [SE 0.09]) of family doctors the most. Cost was negatively valued (coefficient - 0.01, [SE 0.01]), as expected. Preference heterogeneity analysis was conducted after adjusting the interaction terms, and we found that rural residents with higher educational attainment prefer a good attitude more than their counterparts with lower educational attainment. The estimated willingness to pay (WTP) for "high" relative to "low" competence was 441.13 RMB/year, and the WTP for a provider with a "good" attitude relative to a "poor" attitude was 255.77 RMB/year. CONCLUSION The present study suggests that strengthening and improving the quality of primary health care, including the competence and attitudes of family doctors, should be prioritized to increase the uptake of FDCSs. The contract service package, including the annual cost, the insurance reimbursement rate and individualized services, should be redesigned to be congruent with residents having different health statuses and their stated preferences.
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Affiliation(s)
- Peipei Fu
- NHC Key Laboratory of Health Economics and Policy Research, School of Health Care Management, Shandong University, Jinan, 250012 China
| | - Yi Wang
- School of Public Health, Shandong University, Jinan, 250012 China
| | - Shimeng Liu
- Key Lab of Health Technology Assessment, National Health Comission, School of Public Health, Fudan University, Shanghai, China
| | - Jiajia Li
- School of Public Health, Shandong University, Jinan, 250012 China
| | - Qiufeng Gao
- Center for Experimental Economics in Education, Shaanxi Normal University, Xi’an, China
| | - Chengchao Zhou
- Key Lab of Health Economics and Policy Research, School of Public Health, Shandong University, 44 Wen-hua-xi Road, Jinan, 250012 Shandong China
| | - Qingyue Meng
- China Center for Health Development Studies, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing, 100191 China
| | - Sean Sylvia
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
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Yi H, Wu P, Zhang X, Teuwen DE, Sylvia S. Market competition and demand for skills in a credence goods market: Evidence from face-to-face and web-based non-physician clinician training in rural China. PLoS One 2020; 15:e0233955. [PMID: 32555610 PMCID: PMC7302647 DOI: 10.1371/journal.pone.0233955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/13/2020] [Indexed: 11/19/2022] Open
Abstract
Background Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs’ professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the “credence good” nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available. Methods The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC’s participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). Results In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. Conclusions Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.
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Affiliation(s)
- Hongmei Yi
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
- * E-mail:
| | - Paiou Wu
- China Center for Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China
| | - Xiaoyuan Zhang
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, United States of America
| | - Dirk E. Teuwen
- Corporate Societal Responsibility, UCB, Brussels, Belgium
| | - Sean Sylvia
- Department of Health Policy and Management and the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Pitkänen V, Jauhiainen S, Linnosmaa I. Low risk, high reward? Repeated competitive biddings with multiple winners in health care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:483-500. [PMID: 31902025 PMCID: PMC7214509 DOI: 10.1007/s10198-019-01143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 12/03/2019] [Indexed: 06/10/2023]
Abstract
We study physiotherapy providers' prices in repeated competitive biddings where multiple providers are accepted in geographical districts. Historically, only very few districts have rejected any providers. We show that this practice increased prices and analyze the effects the risk of rejection has on prices. Our data are derived from three subsequent competitive biddings. The results show that rejecting at least one provider decreased prices by more than 5% in the next procurement round. The results also indicate that providers have learned to calculate their optimal bids, which has also increased prices. Further, we perform counterfactual policy analysis of a capacity-rule of acceptance. The analysis shows that implementing a systematic acceptance rule results in a trade-off between direct cost savings and service continuity at patients' usual providers.
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Affiliation(s)
- Visa Pitkänen
- Research Department, Social Insurance Institution of Finland, P.O. Box 450, 00056, Helsinki, Finland.
| | - Signe Jauhiainen
- Research Department, Social Insurance Institution of Finland, P.O. Box 450, 00056, Helsinki, Finland
| | - Ismo Linnosmaa
- Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, 70211, Kuopio, Finland
- Centre for Health and Social Economics, National Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
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Chen Y, Ding S, Zheng H, Zhang Y, Yang S. Decision support for personalized hospital choice using the DEX hierarchical model with SMAA. Knowl Inf Syst 2020. [DOI: 10.1007/s10115-020-01448-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gravelle H, Liu D, Propper C, Santos R. Spatial competition and quality: Evidence from the English family doctor market. JOURNAL OF HEALTH ECONOMICS 2019; 68:102249. [PMID: 31698252 DOI: 10.1016/j.jhealeco.2019.102249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
We examine whether family doctor firms in England respond to local competition by increasing their quality. We measure quality in terms of clinical performance and patient-reported satisfaction to capture its multi-dimensional nature. We use a panel covering 8 years for over 8000 English general practices. We measure competition as the number of rival doctors within a small distance and control for a large number of potential confounders. We find that increases in local competition are associated with increases in patient satisfaction and to a lesser extent in clinical quality. However, the magnitude of the effect is small.
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Affiliation(s)
- Hugh Gravelle
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom.
| | - Dan Liu
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom
| | - Carol Propper
- Imperial College London, CMPO University of Bristol, CEPR and IFS, United Kingdom
| | - Rita Santos
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom
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30
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Avdic D, Moscelli G, Pilny A, Sriubaite I. Subjective and objective quality and choice of hospital: Evidence from maternal care services in Germany. JOURNAL OF HEALTH ECONOMICS 2019; 68:102229. [PMID: 31521024 DOI: 10.1016/j.jhealeco.2019.102229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 05/25/2023]
Abstract
We study patient choice of healthcare provider based on both objective and subjective quality measures in the context of maternal care hospital services in Germany. Objective measures are obtained from publicly reported clinical indicators, while subjective measures are based on satisfaction scores from a large and nationwide patient survey. We merge both quality metrics to detailed hospital discharge records and quantify the additional distance expectant mothers are willing to travel to give birth in maternity clinics with higher reported quality. Our results reveal that patients are on average willing to travel 0.1-2.7 additional kilometers for a one standard deviation increase in quality. Patients respond to both objective and subjective quality measures, suggesting that patient satisfaction scores may constitute important complements to clinical indicators when choosing provider.
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Affiliation(s)
- Daniel Avdic
- Centre for Health Economics, Monash Business School, Monash University Level 5, Building H, Caulfield Campus, 900 Dandenong Road, Caulfield East, VIC 3145, Australia.
| | | | - Adam Pilny
- RWI - Leibniz-Institut für Wirtschaftsforschung, Germany
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Cronin CJ, Guilkey DK, Speizer IS. Measurement Error in Discrete Health Facility Choice Models: an Example from Urban Senegal. JOURNAL OF APPLIED ECONOMETRICS (CHICHESTER, ENGLAND) 2019; 34:1102-1120. [PMID: 32153316 PMCID: PMC7062358 DOI: 10.1002/jae.2739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/19/2019] [Indexed: 06/10/2023]
Abstract
We use individual-level health facility choice data from urban Senegal to estimate consumer preferences for facility characteristics related to maternal health services. We find that consumers consider a large number of quality related facility characteristics, as well as travel costs, when making their health facility choice. In contrast to the typical assumption in the literature, our findings indicate that individuals frequently bypass the facility nearest their home. In light of this, we show that the mismeasured data used commonly in the literature produces biased preference estimates; most notably, the literature likely overestimates consumer distaste for travel.
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Affiliation(s)
- Christopher J. Cronin
- Corresponding Author: University of Notre Dame, Department of Economics, 3060 Jenkins Nanovic Halls, Notre Dame, IN 46556; 574-631-0427;
| | - David K. Guilkey
- Department of Economics and Carolina Population Center, University of North Carolina at Chapel Hill
| | - Ilene S. Speizer
- Gillings School of Global Public Health, Department of Maternal and Child Health and Carolina Population Center, University of North Carolina at Chapel Hill
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Brekke KR, Holmås TH, Monstad K, Straume OR. Competition and physician behaviour: Does the competitive environment affect the propensity to issue sickness certificates? JOURNAL OF HEALTH ECONOMICS 2019; 66:117-135. [PMID: 31181454 DOI: 10.1016/j.jhealeco.2019.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 06/09/2023]
Abstract
Competition among physicians is widespread, but compelling empirical evidence on its impact on service provision is limited, mainly due to endogeneity issues. In this paper we exploit that many GPs, in addition to own practice, work in local emergency centres, where the matching of patients to GPs is random. The same GP is observed both with competition (own practice) and without (emergency centre). Using high-dimensional fixed-effect models, we find that GPs with a fee-for-service (fixed-salary) contract are 12 (8) percentage points more likely to certify sick leave at own practice than at the emergency centre. Thus, competition has a positive impact on GPs' sicklisting that is strongly reinforced by financial incentives.
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Affiliation(s)
- Kurt R Brekke
- Department of Economics, Norwegian School of Economics (NHH), Helleveien 30, N-5045 Bergen, Norway.
| | | | - Karin Monstad
- NORCE, Postboks 22 Nygårdstangen, 5838 Bergen, Norway.
| | - Odd Rune Straume
- Department of Economics/NIPE, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal; Department of Economics, University of Bergen, Norway.
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Incentive schemes to increase dementia diagnoses in primary care in England: a retrospective cohort study of unintended consequences. Br J Gen Pract 2019; 69:e154-e163. [PMID: 30803980 DOI: 10.3399/bjgp19x701513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/27/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown. AIM To identify and quantify unintended consequences associated with the DES18 and DIS schemes. DESIGN AND SETTING A retrospective cohort quantitative study of 7079 English primary care practices. METHOD Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics. RESULTS National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators. CONCLUSION The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience.
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Allen T, Whittaker W, Kontopantelis E, Sutton M. Influence of financial and reputational incentives on primary care performance: a longitudinal study. Br J Gen Pract 2018; 68:e811-e818. [PMID: 30397016 PMCID: PMC6255225 DOI: 10.3399/bjgp18x699797] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/25/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time. AIM To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme. DESIGN AND SETTING Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013. METHOD The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards. RESULTS Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013. CONCLUSION In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.
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Affiliation(s)
| | | | | | - Matt Sutton
- School of Health Sciences, University of Manchester, Manchester
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Reuber M, Chappell P, Jackson C, Toerien M. Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BackgroundWe report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another.ObjectivesTo (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making.DesignA mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision.Setting and participantsThe primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated.ResultsDistribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed.LimitationsA main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation.ConclusionsPatient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making.Future researchTo advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence).FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Paul Chappell
- Department of Sociology, University of York, York, UK
| | - Clare Jackson
- Department of Sociology, University of York, York, UK
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Can Urban-Rural Patterns of Hospital Selection Be Changed Using a Report Card Program? A Nationwide Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091827. [PMID: 30149514 PMCID: PMC6164887 DOI: 10.3390/ijerph15091827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/13/2018] [Accepted: 08/22/2018] [Indexed: 11/24/2022]
Abstract
Background: Guiding patients to choose high-quality healthcare providers helps ensure that patients receive excellent care and helps reduce health disparities among patients of different socioeconomic backgrounds. The purpose of this study was to examine and compare the effect of implementing a report-card program on the patterns of hospital selection in patients from different socioeconomic subgroups. Patients undergoing total knee replacement (TKR) surgery were used as the sample population. Methods: A patient-level, retrospective, observational and cross-sectional study design was conducted. Taiwan National Health Insurance claims data were used and all patients in this database who had received TKR between April 2007–March 2008 (prior to report-card program implementation) and between April 2009–March 2010 (after program implementation) were included. Those patients who were under 18 years of age or who lacked area-of-residence or National Health Insurance premium information were excluded. Travelling distance to the hospital and level of hospital performance were used to evaluate the effect of the report-card program. Results: A total of 32,821 patients were included in this study. The results showed that patterns of hospital selection varied based on the socioeconomic characteristics of patients. In terms of travelling distance and hospital selection, the performance of urban and higher income patients was shorter and better, respectively, than their rural and lower-income peers both before and after report-card-program implementation. Moreover, although the results of multivariate analysis showed that the urban-rural difference in travelling distance enlarged (by 4.75 km) after implementation of the report-card program, this increase was shown to not be significantly related to this program. Furthermore, the results revealed that implementation of the report-card program did not significantly affect the urban-rural difference in terms of level of hospital performance. Conclusions: A successful report-card program should ensure that patients in all socioeconomic groups obtain comprehensive information. However, the results of this study indicate that those in higher socioeconomic subgroups attained more benefits from the program than their lower-subgroup peers. Ensuring that all have equal opportunity to access high-quality healthcare providers may therefore be the next issue that needs to be addressed and resolved.
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Mason A, Liu D, Kasteridis P, Goddard M, Jacobs R, Wittenberg R, McGonigal G. Investigating the impact of primary care payments on underdiagnosis in dementia: A difference-in-differences analysis. Int J Geriatr Psychiatry 2018; 33:1090-1097. [PMID: 29851169 PMCID: PMC6704384 DOI: 10.1002/gps.4897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/03/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE In England, two primary care incentive schemes were introduced to increase dementia diagnosis rates to two-thirds of expected levels. This study assesses the effectiveness of these schemes. METHODS We used a difference-in-differences framework to analyse the individual and collective impacts of the incentive schemes: (1) Directed Enhanced Service 18 (DES18: facilitating timely diagnosis of and support for dementia) and (2) the Dementia Identification Scheme (DIS). The dataset included 7529 English general practices, of which 7142 were active throughout the 10-year study period (April 2006 to March 2016). We controlled for a range of factors, including a contemporaneous hospital incentive scheme for dementia. Our dependent variable was the percentage of expected cases that was recorded on practice dementia registers (the "rate"). RESULTS From March 2013 to March 2016, the mean rate rose from 51.8% to 68.6%. Both DES18 and DIS had positive and significant effects. In practices participating in the DES18 scheme, the rate increased by 1.44 percentage points more than the rate for non-participants; DIS had a larger effect, with an increase of 3.59 percentage points. These combined effects increased dementia registers nationally by an estimated 40 767 individuals. Had all practices fully participated in both schemes, the corresponding number would have been 48 685. CONCLUSION The primary care incentive schemes appear to have been effective in closing the gap between recorded and expected prevalence of dementia, but the hospital scheme had no additional discernible effect. This study contributes additional evidence that financial incentives can motivate improved performance in primary care.
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Affiliation(s)
- Anne Mason
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Dan Liu
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | | | | | - Raphael Wittenberg
- Personal Social Services Research UnitLondon School of Economics and Political ScienceLondonUK
| | - Gerard McGonigal
- Department of Medicine for the ElderlyYork Teaching Hospital NHS Foundation TrustYorkNorth YorkshireUK
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Competition in health care: lessons from the English experience. HEALTH ECONOMICS POLICY AND LAW 2018; 13:492-508. [DOI: 10.1017/s1744133117000494] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractThe use of competition and the associated increase in choice in health care is a popular reform model, adopted by many governments across the world. Yet it is also a hotly contested model, with opponents seeing it, at best, as a diversion of energy or a luxury and, at worst, as leading to health care inequality and waste. This paper subjects the use of competition in health care to scrutiny. It begins by examining the theoretical case and then argues that only by looking at evidence can we understand what works and when. The body of the paper examines the evidence for England. For 25 years the United Kingdom has been subject to a series of policy changes which exogenously introduced and then downplayed the use of competition in health care. This makes England a very useful test bed. The paper presents the UK reforms and then discusses the evidence of their impact, examining changes in outcomes, including quality, productivity and the effect on the distribution of health care resources across socio-economic groups. The final section reflects on what can be learnt from these findings.
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Ellegård LM, Dietrichson J, Anell A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? HEALTH ECONOMICS 2018; 27:e39-e54. [PMID: 28685902 PMCID: PMC5836891 DOI: 10.1002/hec.3535] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 03/27/2017] [Accepted: 05/15/2017] [Indexed: 05/05/2023]
Abstract
Antibiotic resistance is a major threat to public health worldwide. As the healthcare sector's use of antibiotics is an important contributor to the development of resistance, it is crucial that physicians only prescribe antibiotics when needed and that they choose narrow-spectrum antibiotics, which act on fewer bacteria types, when possible. Inappropriate use of antibiotics is nonetheless widespread, not least for respiratory tract infections (RTI), a common reason for antibiotics prescriptions. We examine if pay-for-performance (P4P) presents a way to influence primary care physicians' choice of antibiotics. During 2006-2013, 8 Swedish healthcare authorities adopted P4P to make physicians select narrow-spectrum antibiotics more often in the treatment of children with RTI. Exploiting register data on all purchases of RTI antibiotics in a difference-in-differences analysis, we find that P4P significantly increased the share of narrow-spectrum antibiotics. There are no signs that physicians gamed the system by issuing more prescriptions overall.
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Affiliation(s)
| | - Jens Dietrichson
- SFIThe Danish National Centre for Social ResearchCopenhagenDenmark
| | - Anders Anell
- Department of Business AdministrationLund UniversityLundSweden
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Markussen S, Røed K. The market for paid sick leave. JOURNAL OF HEALTH ECONOMICS 2017; 55:244-261. [PMID: 28802747 DOI: 10.1016/j.jhealeco.2017.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 07/08/2017] [Accepted: 07/26/2017] [Indexed: 06/07/2023]
Abstract
In many countries, general practitioners (GPs) are assigned the task of controlling the validity of their own patients' insurance claims. At the same time, they operate in a market where patients are customers free to choose their GP. Are these roles compatible? Can we trust that the gatekeeping decisions are untainted by private economic interests? Based on administrative registers from Norway with records on sick pay certification and GP-patient relationships, we present evidence to the contrary: GPs are more lenient gatekeepers the more competitive is the physician market, and a reputation for lenient gatekeeping increases the demand for their services.
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Affiliation(s)
| | - Knut Røed
- The Ragnar Frisch Centre for Economic Research, Norway
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Glenngård AH, Anell A. Does increased standardisation in health care mean less responsiveness towards individual patients' expectations? A register-based study in Swedish primary care. SAGE Open Med 2017; 5:2050312117704862. [PMID: 28491311 PMCID: PMC5405878 DOI: 10.1177/2050312117704862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/21/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We explore whether standardisation in health care based on evidence on group level and a public health perspective is in conflict with responsiveness towards individual patient's expectations in Swedish primary care. METHODS Using regression analysis, we study the association between patient views about providers' responsiveness and indicators reflecting provider's adherence to evidence-based guidelines, controlled for characteristics related to providers, including patient mix and degree of competition facing providers. Data were taken from two Swedish regions in years 2012 and 2013. RESULTS Patients' views about responsiveness are positively correlated with variables reflecting provider's adherence to evidence-based guidelines regarding treatment of elderly and risk groups, drug reviews and prescription of antibiotics. A high overall illness, private ownership and a high proportion of all visits being with a doctor are positively associated with patient views about responsiveness. The opposite relation was found for a high social deprivation among enrolled individuals and size of practice. There was no systematic variation with respect to the degree of competition facing providers. CONCLUSION Results suggest that responsiveness towards individual patient expectations is compatible with increased standardisation in health care. This is encouraging for health care providers as they are challenged to balance increased demands from both patients and payers.
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Affiliation(s)
| | - Anders Anell
- School of Economics and Management, Lund University, Lund, Sweden
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42
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Santos R, Gravelle H, Propper C. Does Quality Affect Patients' Choice of Doctor? Evidence from England. ECONOMIC JOURNAL (LONDON, ENGLAND) 2017; 127:445-494. [PMID: 28356602 PMCID: PMC5349292 DOI: 10.1111/ecoj.12282] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 01/13/2014] [Indexed: 05/22/2023]
Abstract
Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%.
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Affiliation(s)
| | | | - Carol Propper
- University of BristolImperial College London and CEPR
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Mokienko A, Wangen KR. Disenrollment from general practitioners among chronic patients: a register-based longitudinal study of Norwegian claims data. BMC FAMILY PRACTICE 2016; 17:170. [PMID: 27978811 PMCID: PMC5159957 DOI: 10.1186/s12875-016-0571-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/02/2016] [Indexed: 11/19/2022]
Abstract
Background Norwegian general practitioners (GPs) consult on a variety of conditions with a mix of patient types. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates. Methods Data on 384,947 chronic patients and 3,974 GPs for the years 2009–2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The birth cohorts from 1940 and 1970 (146,906 patients) were included for comparison. Patient and GP characteristics, comorbidity, and patient list composition were analyzed using descriptive statistics. Patients’ voluntary disenrollment was analyzed using logistic regression models. Results The GPs’ proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. The proportions of patients with different chronic diseases were positively correlated, partly due to comorbidity. Patients tended to have lower disenrollment rates from GPs who had higher shares of patients with the same chronic disease. Disenrollment rates were generally lower from GPs with higher shares of patients with arthritis or depression, and higher from GPs who had higher shares of patients with diabetes type 1 and schizophrenia. This was the same in the comparison group. Conclusion Patients with a chronic disease appeared to prefer GPs who have higher shares of patients with the same disease. High shares of patients with some diseases were also negatively associated with disenrollment for all patient groups, while other diseases were positively associated. These findings may reflect the GPs’ general quality, but could alternatively result from the GPs’ specialization in particular diseases. The supportive findings for the comparison group make it more plausible that high shares of chronic patients could indicate GP quality.
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Affiliation(s)
- Anastasia Mokienko
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, Oslo, 0318, Norway.
| | - Knut Reidar Wangen
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, Oslo, 0318, Norway
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Gutacker N, Siciliani L, Moscelli G, Gravelle H. Choice of hospital: Which type of quality matters? JOURNAL OF HEALTH ECONOMICS 2016; 50:230-246. [PMID: 27590088 PMCID: PMC5138156 DOI: 10.1016/j.jhealeco.2016.08.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 06/27/2016] [Accepted: 08/16/2016] [Indexed: 05/25/2023]
Abstract
The implications of hospital quality competition depend on what type of quality affects choice of hospital. Previous studies of quality and choice of hospitals have used crude measures of quality such as mortality and readmission rates rather than measures of the health gain from specific treatments. We estimate multinomial logit models of hospital choice by patients undergoing hip replacement surgery in the English NHS to test whether hospital demand responds to quality as measured by detailed patient reports of health before and after hip replacement. We find that a one standard deviation increase in average health gain increases demand by up to 10%. The more traditional measures of hospital quality are less important in determining hospital choice.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, York, United Kingdom.
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, United Kingdom
| | - Giuseppe Moscelli
- Centre for Health Economics, University of York, York, United Kingdom
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, United Kingdom
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Moscelli G, Siciliani L, Gutacker N, Gravelle H. Location, quality and choice of hospital: Evidence from England 2002-2013. REGIONAL SCIENCE AND URBAN ECONOMICS 2016; 60:112-124. [PMID: 27766000 PMCID: PMC5063539 DOI: 10.1016/j.regsciurbeco.2016.07.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 06/30/2016] [Accepted: 07/03/2016] [Indexed: 05/16/2023]
Abstract
We investigate (a) how patient choice of hospital for elective hip replacement is influenced by distance, quality and waiting times, (b) differences in choices between patients in urban and rural locations, (c) the relationship between hospitals' elasticities of demand to quality and the number of local rivals, and how these changed after relaxation of constraints on hospital choice in England in 2006. Using a data set on over 500,000 elective hip replacement patients over the period 2002 to 2013 we find that patients became more likely to travel to a provider with higher quality or lower waiting times, the proportion of patients bypassing their nearest provider increased from 25% to almost 50%, and hospital elasticity of demand with respect to own quality increased. By 2013 average hospital demand elasticity with respect to readmission rates and waiting times were - 0.2 and - 0.04. Providers facing more rivals had demand that was more elastic with respect to quality and waiting times. Patients from rural areas have smaller disutility from distance.
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Affiliation(s)
- Giuseppe Moscelli
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York YO10 5DD, United Kingdom
| | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York YO10 5DD, United Kingdom
| | - Nils Gutacker
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York YO10 5DD, United Kingdom
| | - Hugh Gravelle
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York YO10 5DD, United Kingdom
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