European health policy challenges

Willingness to Pay for Health-Related Quality of Life Gains in Relation to Disease Severity and the Age of Patients

OBJECTIVES

Decision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease.

METHODS

We obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients' disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP.

RESULTS

Respondents' WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains.

CONCLUSIONS

Our results suggest that-if the aim is to align resource-allocation decisions in healthcare with societal preferences-currently applied equity weights do not suffice.

Physicians' perceptions of quality of care, professional autonomy, and job satisfaction in Canada, Norway, and the United States

Background

We lack national and cross-national studies of physicians’ perceptions of quality of patient care, professional autonomy, and job satisfaction to inform clinicians and policymakers. This study aims to compare such perceptions in Canada, the United States (U.S.), and Norway.

Methods

We analyzed data from large, nationwide, representative samples of physicians in Canada (n = 3,083), the U.S. (n = 6,628), and Norway (n = 638), examining demographics, job satisfaction, and professional autonomy.

Results

Among U.S. physicians, 79% strongly agreed/agreed they could provide high quality patient care vs. only 46% of Canadian and 59% of Norwegian physicians. U.S. physicians also perceived more clinical autonomy and time with their patients, with differences remaining significant even after controlling for age, gender, and clinical hours. Women reported less adequate time, clinical freedom, and ability to provide high-quality care. Country differences were the strongest predictors for the professional autonomy variables. In all three countries, physicians’ perceptions of quality of care, clinical freedom, and time with patients influenced their overall job satisfaction. Fewer U.S. physicians reported their overall job satisfaction to be at-least-somewhat satisfied than did Norwegian and Canadian physicians.

Conclusions

U.S. physicians perceived higher quality of patient care and greater professional autonomy, but somewhat lower job satisfaction than their colleagues in Norway and Canada. Differences in health care system financing and delivery might help explain this difference; Canada and Norway have more publicly-financed, not-for-profit health care delivery systems, vs. a more-privately-financed and profit-driven system in the U.S. None of these three highly-resourced countries, however, seem to have achieved an ideal health care system from the perspective of their physicians.

Moral hazard and supplier-induced demand: empirical evidence in general practice

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Getting health reforms right: what lessons from an Italian case?

Over the past few years (2001–2007), the Italian National Health Service has been undergoing an important process of decentralization with a significant transfer of powers and responsibilities from the central government to the Regions. In this context, a particularly innovative example is represented by the case of Marche Region that extensively reformed its health-care system. For the analysis of this case, we used a theoretical framework that describes a health-care system in terms of components and goals. Policy-makers can act on the structural components of the system influencing the behaviour of individuals and organizations in order to lead the system towards the achievement of key performance goals. Marche regional Government was able to improve the system in crucial areas (clinical appropriateness and economic equilibrium) by intervening on institutional arrangements (particularly on the number and dimension of health-care delivery organizations) and on key control knobs (particularly planning and control mechanisms and the information system). Some conditions have allowed Marche policy-maker to successfully carry out this extensive process of reforms, particularly: (1) a shared sense of urgency; (2) agreement on the identification of problems and on the relative reform strategies to adopt; (3) coordination of all change strategies through a precise and clear long-term plan aimed at developing an integrated health-care delivery network.

Why do patients bypass the nearest hospital? An empirical analysis for orthopaedic care and neurosurgery in the Netherlands

Using data for 2003, we find that both for non-emergency orthopaedic care (38%) and neurosurgery (54%) numerous Dutch patients did not visit the nearest hospital. Our estimation results show that extra travel time negatively influences the probability of hospital bypassing. Good waiting time performance by the nearest hospital also significantly decreases the likelihood of a bypass decision. Patients seem to place a lower negative value on extra travel time for orthopaedic care than for neurosurgery. The valuation of shorter waiting time also varies between these two types of hospital care. A good performance of the nearest hospital on waiting time decreases the likelihood of a bypass decision most for neurosurgery. In both samples, patients are more likely to bypass the nearest hospital when it is a university medical centre or a tertiary teaching hospital. Patient attributes, such as age and social status, are also found to significantly affect hospital bypassing. From our analysis it follows that both patient and hospital care heterogeneity should be taken into account when assessing the substitutability of hospitals.