Competition and quality indicators in the health care sector: empirical evidence from the Dutch hospital sector

Does hospital competition improve the quality of outpatient care? - empirical evidence from a quasi-experiment in a Chinese city

BACKGROUND

Although countries worldwide have launched a series of pro-competition reforms, the literature on the impacts of hospital competition has produced a complex and contradictory picture. This study examined whether hospital competition contributed to an increase in the quality of outpatient care.

METHODS

The dataset comprises encounter data on 406,664 outpatients with influenza between 2015 and 2019 in China. Competition was measured using the Herfindahl-Hirschman index (HHI). Whether patients had 14-day follow-up encounter for influenza at any healthcare facility, outpatient facility, and hospital outpatient department were the three quality outcomes assessed. Binary regression models with crossed random intercepts were constructed to estimate the impacts of the HHI on the quality of outpatient care. The intensity of nighttime lights was employed as an instrumental variable to address the endogenous relationship between the HHI and the quality of outpatient care.

RESULTS

We demonstrated that an increase in the degree of hospital competition was associated with improved quality of outpatient care. For each 1% increase in the degree of hospital competition, an individual's risk of having a 14-day follow-up encounter for influenza at any healthcare facility, outpatient facility, and hospital outpatient department fell by 34.9%, 18.3%, and 20.8%, respectively. The impacts of hospital competition on improving the quality of outpatient care were more substantial among females, individuals who used the Urban and Rural Residents Basic Medical Insurance to pay for their medical costs, individuals who visited accredited hospitals, and adults aged 25 to 64 years when compared with their counterparts.

CONCLUSION

This study demonstrated that hospital competition contributed to better quality of outpatient care under a regime with a regulated ceiling price. Competition is suggested to be promoted in the outpatient care market where hospitals have control over quality and government sets a limit on the prices that hospitals may charge.

Association between hospital competition and quality of prostate cancer care

BACKGROUND

Hospitals account for approximately 6% of United States' gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association.

METHODS

Retrospective study using Surveillance, Epidemiology, and End Results (SEER) - Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias.

RESULTS

Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15-1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans.

CONCLUSIONS

Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.

Improving Performance in Complex Surroundings: A Mixed Methods Evaluation of Two Hospital Strategies in the Netherlands

BACKGROUND

Hospital strategies aimed at increasing quality of care and simultaneously reducing costs show potential to improve healthcare, but knowledge on real-world effectiveness is limited. In 2014, two Dutch hospitals introduced such quality-driven strategies. Our aim was to evaluate contexts, mechanisms, and outcomes of both strategies using multiple perspectives.

METHODS

We conducted a mixed methods evaluation. Four streams of data were collected and analysed: (1) semi-structured interviewing of 62 stakeholders, such as medical doctors, nurses, managers, general practitioners (GPs), and consultants; (2) financial statements of both organisations and other hospitals in the Netherlands (counterfactual); (3) national database of quality indicators, and patient-reported experiences; and (4) existing material on strategy development and effects.

RESULTS

Both strategies resulted in a relative decrease in volume of care within the hospital, while quality of care has not been affected negatively. One hospital failed to cut operating costs sufficiently, resulting in declining profit margins. We identified six main mechanisms that impacted these outcomes: (1) Quality-improvement projects spur change and commitment; (2) increased coordination between hospital and primary care leads to substitution of care; (3) insufficient use of data and support hinder quality improvement; (4) scaling down hospital facilities is required to convert volume reductions to cost savings; (5) shared savings through global budgets lead to shared efforts between payer and hospital; and (6) financial security for physicians facilitates shift towards quality-driven care.

CONCLUSION

This integrated analysis of mixed data sources demonstrated that the institution-wide nature of the strategies has induced a shift from a focus on production towards quality of care. Longer-term (financial) sustainability of hospital strategies aimed at decelerating production growth requires significant efforts in reducing fixed costs. This strategy poses financial risks for the hospital if operating costs are insufficiently reduced or if payer alignment is compromised.

The effects of market concentration on health care price and quality in hospital markets in Ibadan, Nigeria

Evidence about the Nigerian health indicators show that the quality of health care in Nigeria is low and inflation of health care prices also persists. Theoretically, by observing the market concentration, inferences can be drawn as to how hospitals conduct themselves, which allows the evaluation of the market performance. Therefore, the effects of market concentration on the health care price and quality were examined. Market concentration was measured by Herfindahl Hirschman Index (HHI) and four hospital concentration ratios (CR₄). The values of HHI were disaggregated into the less and more concentrated markets. Quality of health care was measured by the staff-nurse-patient ratio. Ordinary Least Square (OLS) was used to estimate the effects of market concentration on price and quality of health care. The price of health care was found to be 13.4% lower in the less concentrated markets than in the more concentrated market. Income significantly and positively influenced health care prices by 17.8%. Also, a low HHI lead to 33.4% increase in Staff-nurse Patient Ratio (SPR) indicating that the quality of health care was higher in less concentrated markets as hospitals increased the treatment intensity via staff-nurse patient ratio. A less concentrated market is linked with higher health care quality and lower health care prices. Therefore, a strategy that will reduce market concentration so as to enhance consumer welfare in terms of price and quality is recommended.

Effects of the reform of the Dutch healthcare into managed competition: Results of a Delphi study among experts

BACKGROUND

In 2006 a major healthcare reform was introduced in the Netherlands, implying managed competition. This study explored the level of consensus on the outcomes and desired changes of this new system, and differences between stakeholder groups.

METHODS

A three-round Delphi-study was conducted among Dutch healthcare insurers, health economists, and professionals in general practice (GP) care and mental health (MH) care. In the first round, 20 experts indicated the most important advantages and disadvantages of the Dutch managed competition, and desired changes. Experts in the second (n = 106) and third round (N = 88) rated the importance of the 88 factors identified in the first round.

RESULTS

Only healthcare insurers reached consensus on important advantages (i.e. improved efficiency; room for choice). Health economists reached almost no consensus on any factors. GP and MH-care professionals reached most consensus on disadvantages (i.e. focus on price over quality, increased bureaucracy) and desired changes (i.e. reduce bargaining power of healthcare insurers; increase attention for care of complex patients); half of them suggested abolishment of managed competition.

CONCLUSION

GP and MH-care professionals were most dissatisfied and suggested several changes or even abolishment of the 2006 reform; healthcare insurers mentioned some benefits. This level of dissatisfaction among health care professionals indicates that there is room for improvement, preferably developed in conjunction with stakeholders.

Perceived Competition and Process of Care in Rural China

Purpose

Although there is much debate about the effect of hospital competition on healthcare quality, its impact on the process of care remains unclear. This study aimed to determine whether hospital competition improves the process of care in rural China.

Patients and Methods

The county hospital questionnaire survey data and the randomly sampled medical records of bacterial pneumonia patients in 2015 in rural area of Guizhou, China, were used in this study. The processes of care for bacterial pneumonia were measured by the following three measures: 1) oxygenation assessment, 2) antibiotic treatment, and 3) first antibiotic treatment within 6 hours after admission. Hospital competition was measured by asking hospital directors to rate the competition pressure they perceive from other hospitals. Multivariate logistic regression models were employed to determine the relationship between perceived competition and the processes of care for patients with bacterial pneumonia.

Results

A total of 2167 bacterial pneumonia patients from 24 county hospitals in 2015 were included in our study. Our results suggested that the likelihood of receiving antibiotic treatment and first antibiotic treatment within 6 hours after admission was significantly higher in the hospitals perceiving higher competition pressure. However, no significant relationship was found between perceived competition and oxygenation assessment for patients with bacterial pneumonia.

Conclusion

This study revealed the role of perceived competition in improving the process of care under the fee-for-service payment system and provided empirical evidence to support the pro-competition policies in China’s new round of national healthcare reform.

Hospital competition and the expenses for treatments of acute and non-acute common diseases: evidence from China

Background

Because there is heterogeneity in disease types, competition among hospitals could be influenced in various ways by service provision for diseases with different characteristics. Limited studies have focused on this matter. This study aims to evaluate and compare the relationships between hospital competition and the expenses of prostatectomies (elective surgery, representing treatments of non-acute common diseases) and appendectomies (emergency surgery, representing treatments of acute common diseases).

Methods

Multivariable log-linear models were constructed to determine the association between hospital competition and the expenses of prostatectomies and appendectomies. The fixed-radius Herfindahl-Hirschman Index was employed to measure hospital competition.

Results

We collected data on 13,958 inpatients from the hospital discharge data of Sichuan Province in China from September to December 2016. The data included 3578 prostatectomy patients and 10,380 appendectomy patients. The results showed that greater competition was associated with a lower total hospital charge for prostatectomy (p = 0.006) but a higher charge for appendectomy (p <  0.001). The subcategory analysis showed that greater competition was consistently associated with lower out-of-pocket (OOP) and higher reimbursement for both surgeries.

Conclusions

Greater competition was significantly associated with lower total hospital charges for prostatectomies, while the opposite was true for appendectomies. Furthermore, greater competition was consistently associated with lower OOP but higher reimbursement for both surgeries. This study provides new evidence concerning the heterogeneous roles of competition in service provision for non-acute and acute common diseases. The findings of this study indicate that the pro-competition policy is a viable option for the Chinese government to relieve patients’ financial burden (OOP). Our findings also provide references and insights for other countries facing similar challenges.

Assessing the relationship between healthcare market competition and medical care quality under Taiwan's National Health Insurance programme

Background

There is still significant uncertainty as to whether market competition raises or lowers clinical quality in publicly funded healthcare systems. We attempted to assess the effects of market competition on inpatient care quality of stroke patients in a retrospective study of the universal single-payer health insurance system in Taiwan.

Methods

In this 11-year population-based study, we conducted a pooled time-series cross-sectional analysis with a fixed-effects model and the Hausman test approach by utilizing two nationwide datasets: the National Health Insurance Research Database and the National Hospital and Services Survey in Taiwan. Patients who were admitted to a hospital for ischemic or hemorrhagic stroke were enrolled. After excluding patients with a previous history of stroke and those with different types of stroke, 247 379 ischemic and 79 741 hemorrhagic stroke patients were included in our analysis. Four outcome indicators were applied: the in-hospital mortality rate, 30-day post-operative complication rate, 14-day re-admission rate and 30-day re-admission rate.

Results

Market competition exerted a negative or negligible effect on the medical care quality of stroke patients. Compared to hospitals located in a highly competitive market, in-hospital mortality rates for hemorrhagic stroke patients were significantly lower in moderately (β = -0.05, P < 0.01) and less competitive markets (β = -0.05, P < 0.01). Conversely, the impact of market competition on the quality of care of ischemic stroke patients was insignificant.

Conclusions

Simply fostering market competition might not achieve the objective of improving the quality of health care. Other health policy actions need to be contemplated.

An update on: long-term outcomes of penile prostheses for the treatment of erectile dysfunction

INTRODUCTION

Penile prosthesis placement is the gold standard for the treatment of erectile dysfunction (ED) refractory to medical therapy; however, limited data exist on the long-term outcomes of these devices.

AREAS COVERED

A PubMed search focused on long-term outcomes of penile prosthetics was performed. Studies with a follow-up of less than 5 years were excluded. Included studies were arranged chronologically by implant date to identify trends in device lifetime. Data were further scrutinized to separate device failure secondary to mechanical malfunction from device failure secondary to infection.

EXPERT OPINION

Limited data prevent accurate 15-year predictions for modern prosthetics. The 5- and 10-year overall survival of modern prosthetics is estimated to be 90.4% and 86.6%, respectively. Infection rates are estimated to be 1.5% and 1.8% at 8 and 10 years, respectively. While great strides have been made in device design, there is still potential for advancement in both infection rate reduction and mechanical improvement. The combination of increased collaboration between implanting urologists and engineers from prosthetic device companies and improved, prospectively collected data will usher prosthetic urology into its next era.

Does Hospital Competition Harm Inpatient Quality? Empirical Evidence from Shanxi, China

This study aimed to determine whether hospital competition is associated with improved in-hospital mortality in Shanxi, China. We included a total of 46,959 hospitalizations for acute myocardial infarction (AMI) and 44,063 hospitalizations for pneumonia from 2015 to 2017. Hospital competition was measured as Herfindahl⁻Hirschman Index based on the patient predicted flow approach. Two-level random-intercept logistic models were applied to explore the effects of hospital competition on quality for both AMI and pneumonia diagnoses. Hospital competition exerts negative or negligible effects on inpatient quality of care, and the pattern of competition effects on quality varies by specific diseases. While hospital competition is insignificantly correlated with lower AMI in-hospital mortality (odds ratio (OR): 0.94, 95% confidence interval (CI): 0.77⁻1.11), high hospital competition was, in fact, associated with higher in-hospital mortality for pneumonia patients (OR: 1.99, 95% CI: 1.51⁻2.64). Our study suggests that simply encouraging hospital competition may not provide effective channels to improve inpatient quality of health care in China's current health care system.