Did the corporatization of Portuguese hospitals significantly change their productivity?

A network Data Envelopment Analysis to estimate nations' efficiency in the fight against SARS-CoV-2

The ongoing outbreak of SARS-CoV-2 has been deeply impacting health systems worldwide. In this context, it is pivotal to measure the efficiency of different nations' response to the pandemic, whose insights can be used by governments and health authorities worldwide to improve their national COVID-19 strategies. Hence, we propose a network Data Envelopment Analysis (DEA) to estimate the efficiencies of fifty-five countries in the current crisis, including the thirty-seven Organisation for Economic Co-operation and Development (OECD) member countries, six OECD prospective members, four OECD key partners, and eight other countries. The network DEA model is designed as a general series structure with five single-division stages - population, contagion, triage, hospitalisation, and intensive care unit admission -, and considers an output maximisation orientation, denoting a social perspective, and an input minimisation orientation, denoting a financial perspective. It includes inputs related to health costs, desirable and undesirable intermediate products related to the use of personal protective equipment and infected population, respectively, and desirable and undesirable outputs regarding COVID-19 recoveries and deaths, respectively. To the best of the authors' knowledge, this is the first study proposing a cross-country efficiency measurement using a network DEA within the context of the COVID-19 crisis. The study concludes that Estonia, Iceland, Latvia, Luxembourg, the Netherlands, and New Zealand are the countries exhibiting higher mean system efficiencies. Their national COVID-19 strategies should be studied, adapted, and used by countries exhibiting worse performances. In addition, the observation of countries with large populations presenting worse mean efficiency scores is statistically significant.

Assessing the impact of COVID-19 on the efficiency of Portuguese state-owned enterprise hospitals

This paper uses Value-Based Data Envelopment Analysis (VBDEA), to assess the impact of the COVID-19 pandemic on the efficiency of 37 state-owned enterprises (SOE) hospitals by employing data publicly available from the Portuguese Health Service database between January and November 2019 and 2020, respectively. Furthermore, a productivity index (specifically adjusted to the VBDEA approach) is also used that allows identifying which factors are behind the relative efficiency changes of these hospitals. The factors considered to perform the efficiency assessment of the Portuguese SOE hospitals include labour, capacity, and activity-related indicators. Out of the 37 SOE hospitals, 21 and 17 were efficient in 2019 and 2020, respectively. Irrespective of the value functions considered, the hospitals more often viewed as a reference for best practices were Santa Maria Maior, Tâmega e Sousa and Entre Douro e Vouga. Santa Maria Maior and Algarve were the only hospitals found to be robustly efficient for both years. Overall, the majority of SOE hospitals showed negative productivity (except for Évora and Santa Maria Maior) and all of them presented negative technological change, thus highlighting the massive impact that the COVID-19 outbreak has had on the performance of these hospitals. An additional conclusion is that inefficient hospitals substantially increased all their resources in 2020 as compared to inefficient hospitals in 2019, suggesting that the inefficiency of these hospitals was not due to the lack of resources. Finally, irrespective of the model employed, the hospitals located in the Portuguese northern region were more resilient to the COVID-19 crisis. All in all, to become more resilient (even for future COVID-19 outbreaks), hospitals should undertake changes that are advantageous irrespective of the obstacles they face and that are even beneficial during normal times. A culture of cooperation within and across hospitals should also be cultivated, which allows exchanging resources where they can be used more efficiently.

Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?

INTRODUCTION

Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment.

OBJECTIVES

This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access.

METHODS

We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access.

RESULTS

A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures.

CONCLUSIONS

In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.

Countries' experiences in reforming hospital administration structure based on the Parker and Harding model: A systematic review study

In recent years, many reforms have been made on the structure of hospital administration, most of which are proposed by Parker-Harding models. Therefore, the purpose of this study is to systematically review global relevant experiences in reforming the hospital governance structure with emphasis on the Parker-Harding model. Required information was collected using keywords autonomization, corporatization, privatization, decentralization, reform, hospital autonomy, governance model, and structural reform in databases such as EMBASE, PubMed, Scopus, SID, MagIran, and other resources. Information on the subjects under study was collected from 1990 to 2020. The content extraction method was used for data extraction and data analysis. Thirty-nine sources were included in the study. Results of searching for relevant evidence on a variety of hospital governance models (government, board, corporate, and private) based on the Parker-Harding model in four categories including strengths (31), weaknesses (30), outcomes (26), and interventions (21) are outlined. In this study, strengths, weaknesses, outcomes, and corrective interventions were presented for different models of hospital administration that could be used by healthcare policymakers. Also, According to the results of this study, governmental model less recommended.

Efficiency and Productivity Change of Public Hospitals in Panama: Do Management Schemes Matter?

In Latin American and Caribbean countries, the main concern of public health care managers has been traditionally placed on problems related to funding, payment mechanisms, and equity of access. However, more recently, there is a growing interest in improving the levels of efficiency and reducing costs in the provision of health services. In this paper we focus on measuring the technical efficiency and productivity change of public hospitals in Panama using bootstrapped Malmquist indices, which allows us to assess the statistical significance of changes in productivity, efficiency, and technology. Specifically, we are interested in comparing the performance of hospitals belonging to the two different management schemes coexisting in the country, the Social Security Fund (SSF) and the Ministry of Health (MoH). Our dataset includes data about 22 public hospitals (11 for each model) during the period between 2005 and 2015. The results showed that the productivity growth of hospitals belonging to the SSF has been much higher than that of the hospitals belonging to the Ministry of Health over the evaluated period (almost 4% compared to 1.5%, respectively). The main explanation for these divergences is the superior growth of technological change in the former hospitals, especially in the final years of the evaluated period.

An Incentive-Based Framework for Analyzing the Alignment of Institutional Interventions in the Public Primary Healthcare Sector: The Portuguese Case

Over the years, the Portuguese National Health Service has undergone several reforms to face the challenges posed by internal and external factors on the access to and quality of its health services. One of its most recent reforms addressed the primary healthcare sector, where understanding the incentives behind the actors of the inherent institutional interventions and how they are aligned with the governing health policies is paramount for reformative success. With the purpose of acknowledging the alignment of the primary healthcare sector's institutional interventions from an incentive-based perspective, we propose a framework resting on a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, which was built in cooperation with a panel of decision-making actors from the Portuguese Ministry of Health. In the end, we derive possible policy implications and strategies. This holistic approach highlighted the positive impact of the primary healthcare reform in the upgrade of physical resources and human capital but stressed the geosocial asymmetries and the lack of intra- and inter-sectorial coordination. The proposed framework serves also as a guideline for future primary healthcare reforms, both national- and internationally.

A critical look at the Portuguese public-private partnerships in healthcare

The pre-conceived idea that contracts in a public-private partnership (PPP) regime, in healthcare or in any other economic sector, are, as a rule, ruinous and appealing for only a share of the stakeholders, lacks a solid basis that confirms it. This idea, outset and nurtured by the media, has been instigating the distrust of the users who, in turn, demand a more rigorous and efficient utilisation of public resources. Being Portugal in the top of countries that resort to PPPs, it is urgent to inquire if its respective contracts originated an inefficient and ineffective management of resources. It is precisely this discussion that we address in this paper, focusing our efforts in the Portuguese healthcare sector.

Financial Crisis in Portugal: Effects in the Health Care Sector

Portugal has faced an economic and financial crisis that began circa FY2009 and whose effects are still ongoing. In FY2011, the Portuguese state and the European triumvirate - composed of the European Commission, the International Monetary Fund, and the European Central Bank - signed the Memoranda of Understanding. This troika agreement aimed to improve the operational efficiency of public services. This crisis had a considerable impact on the Portuguese citizens' life and productivity, as well as on the public health care system. Cuts over public expenditures have been made to reduce the risk of noncompliance with budgetary targets, despite their potential impact on quality and access to health care services. We analyzed the main policies and measures undertaken by the Portuguese Ministry of Health with respect to the bailout program associated with the troika agreement. Then, we focused on the budgetary cuts-related risks over the social performance of the care system. Evidence suggests that structural reforms in the health care sector in the troika period had positive effects in terms of drugs administration and consumption, on the one hand, and secondary care expenditures reduction, on the other hand. Nonetheless, we observed some divestitures on infrastructures and the worsening of access to health care services.

Technical efficiency of Portuguese public hospitals: A comparative analysis across the five regions of Portugal

The present study aims to analyse the efficiency scores of hospital units, with reference to the five Portuguese health administrative regions (North, Centre, Lisbon and Tagus Valley, Alentejo, and Algarve). This paper contextualizes the process of decentralization of health in Portugal (started 1993) as well as the hospitals' corporatization and merging reforms (started 2002). These reforms aimed to meet health care needs by optimizing costs, improving efficiency, and broadening both access and quality in health services. Data envelopment analysis was used to quantify and compare the efficiencies of 27 hospitals heterogeneously distributed by five administrative regions. The results show a large average performance across the country. However, there are regions with scores larger than the national average and others with inferior results. This interregional diversity points towards disparities that deserve special attention from the policymakers and hospital managers.

The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis

The Portuguese health system concentrates most of its activity in a National Health Service, created in 1979 to promote universal and general access. The National Health Service should ensure equity, efficiency, and quality of all health care delivered services. This study assesses the impact of health care policies between 2002 and 2017, focusing on 3 timeframes: the adoption and adaptation of New Public Management principles to the health care sector (2002 to 2010), the economic and financial crisis period (2011-2015), and the postcrisis recovery period (2016-2017). The current study evaluates the main policy measures in the health sector, presenting their impacts in terms of access, efficiency, accountability, and costs over those 3 economic periods. It was verified that not all the measures implemented by the successive governments obtained the desired outcomes, generating even costs increase, apart from the austerity period in which health expenditure showed a significant reduction because of the financial constraints.

Doctors, nurses, and the optimal scale size in the Portuguese public hospitals

This study analyses the scale efficiency, optimal scale for hospital clinical staff, and the exogenous dimensions that can be associated with them. They offer useful insights for health policy design, particularly when human resources need to be reallocated across the country due to uneven distributions. Initial data considered a sample of 27 Portuguese general/acute-care public hospitals belonging to the National Health Service, observed between 2013 and 2016. This resulted into a sample of 108 hospitals-year. Data Envelopment Analysis was employed to assess scale efficiency and optimal scale associated with the workforce and at the overall hospital level. Quality and access to health care services adjusted the measures of scale efficiency and optimal size. A multiple regression analysis was carried out to associate optimal scale and scale efficiency to demographics. Optimal scale centred on 274 full-time equivalent (FTE) doctors and 475 FTE nurses. Overall, there is an excess of FTE doctors and FTE nurses, even after potential reallocations. There is an uneven distribution of health workforce, with excess of staff located in urban areas. Hospitals productivity would increase if they reduced their operational scale. Drivers of potential change include population size, childhood mortality rate, birth rate, and purchasing power parity. Health policies are required, not to hire more staff, but rather to promote the reallocation of employees to deprived regions.

The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada

OBJECTIVE

To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier.

DATA SOURCES/STUDY SETTING

Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013.

STUDY DESIGN

We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression.

DATA COLLECTION/EXTRACTION METHODS

Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB.

PRINCIPAL FINDINGS

On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients.

CONCLUSIONS

The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains.

Integrated Analysis of Healthcare Efficiency: A Systematic Review

Data Envelopment Analysis (DEA) has been used as a performance measurement tool in efficiency assessment of healthcare systems. However, over the years, researchers and health practitioners presented the theoretical and methodological limitations of DEA that limits the full view of healthcare efficiency. To address these limitations, a commonly used strategy is to integrate other statistical methods and techniques with DEA to provide better efficiency evaluation. This paper reviews 57 studies with DEA applications in the healthcare industry to illustrate the integrated analysis of healthcare efficiency. With DEA as the central method, regression models in conjunction with statistical tests are commonly used. Input-oriented radial DEA models using predominantly capacity-related inputs and activity-related outputs and following either constant return to scale or variable return to scale assumptions are mostly applied to measure healthcare efficiency.

Competition in the Dutch hospital sector: an analysis of health care volume and cost

This paper evaluates the impact of market competition on health care volume and cost. At the start of 2005, the financing system of Dutch hospitals started to be gradually changed from a closed-end budgeting system to a non-regulated price competitive prospective reimbursement system. The gradual implementation of price competition is a 'natural experiment' that provides a unique opportunity to analyze the effects of market competition on hospital behavior. We have access to a unique database, which contains hospital discharge data of diagnosis treatment combinations (DBCs) of individual patients, including detailed care activities. Difference-in-difference estimates show that the implementation of market-based competition leads to relatively lower total costs, production volume and number of activities overall. Difference-in-difference estimates on treatment level show that the average costs for outpatient DBCs decreased due to a decrease in the number of activities per DBC. The introduction of market competition led to an increase of average costs of inpatient DBCs. Since both volume and number of activities have not changed significantly, we conclude that the cost increase is likely the result of more expensive activities. A possible explanation for our finding is that hospitals look for possible efficiency improvements in predominantly outpatient care products that are relatively straightforward, using easily analyzable technologies. The effects of competition on average cost and the relative shares of inpatient and outpatient treatments on specialty level are significant but contrary for cardiology and orthopedics, suggesting that specialties react differently to competitive incentives.

Identifying congestion levels, sources and determinants on intensive care units: the Portuguese case

Healthcare systems are facing a resources scarcity so they must be efficiently managed. On the other hand, it is commonly accepted that the higher the consumed resources, the higher the hospital production, although this is not true in practice. Congestion on inputs is an economic concept dealing with such situation and it is defined as the decreasing of outputs due to some resources overuse. This scenario gets worse when inpatients' high severity requires a strict and effective resources management, as happens in Intensive Care Units (ICU). The present paper employs a set of nonparametric models to evaluate congestion levels, sources and determinants in Portuguese Intensive Care Units. Nonparametric models based on Data Envelopment Analysis are employed to assess both radial and non-radial (in)efficiency levels and sources. The environment adjustment models and bootstrapping are used to correct possible bias, to remove the deterministic nature of nonparametric models and to get a statistical background on results. Considerable inefficiency and congestion levels were identified, as well as the congestion determinants, including the ICU specialty and complexity, the hospital differentiation degree and population demography. Both the costs associated with staff and the length of stay are the main sources of (weak) congestion in ICUs. ICUs management shall make some efforts towards resource allocation to prevent the congestion effect. Those efforts shall, in general, be focused on costs with staff and hospital days, although these congestion sources may vary across hospitals and ICU services, once several congestion determinants were identified.

Should inpatients be adjusted by their complexity and severity for efficiency assessment? Evidence from Portugal

Hospital efficiency analysis depends largely on the model specifications. This study discusses the importance of the case-mix index (CMI) to homogenize the sample of inpatient discharges. It proposes a new index where they are classified by service, since it is usual to have lack of data to compute the CMI and this can influence the credibility of results. Data from the Portuguese national diagnosis-related group (DRG) database was utilized. Three different approaches are developed in this paper, based on locally convex order-m method as well as on translog functions. The first one correlates the efficiency with different inpatients weighting schemes, by using the Nadaraya-Watson method. The second approach compares different frontiers that have been computed using the different weighting schemes. Finally, by using bootstrap, the paper investigates whether the inclusion of severity/ complexity-related variables in the model statistically modifies the results. It has been shown that, under the Portuguese healthcare framework, if the model is environment corrected (which should include epidemiological and main political/ structural health reforms variables), then the severity adjustment of inpatients is pointless. The employment of an inpatient-weighting scheme, such as the CMI, may introduce significant frontier shift, thus its absence is not recommended in productivity evolution analyzes. The CMI shifts the efficiency frontier, but not the relative position of units against it (the last scenario if exogenous variables are present).