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El-Shal A, Cubi-Molla P, Jofre-Bonet M. Discontinuation of performance-based financing in primary health care: impact on family planning and maternal and child health. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:109-132. [PMID: 35583836 PMCID: PMC9115741 DOI: 10.1007/s10754-022-09333-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 04/17/2022] [Accepted: 04/26/2022] [Indexed: 06/01/2023]
Abstract
Performance-based financing (PBF) is advocated as an effective means to improve the quality of care by changing healthcare providers' behavior. However, there is limited evidence on its effectiveness in low- and middle-income countries and on its implementation in primary care settings. Evidence on the effect of discontinuing PBF is even more limited than that of introducing PBF schemes. We estimate the effects of discontinuing PBF in Egypt on family planning, maternal health, and child health outcomes. We use a difference-in-differences (DiD) model with fixed effects, exploiting a unique dataset of six waves of spatially constructed facility-level health outcomes. We find that discontinuing performance-based incentives to providers had a negative effect on the knowledge of contraceptive methods, iron supplementation during pregnancy, the prevalence of childhood acute respiratory infection, and, more importantly, under-five child mortality, all of which were indirectly targeted by the PBF scheme. No significant effects are reported for directly targeted outcomes. Our findings suggest that PBF can induce permanent changes in providers' behavior, but this may come at the expense of non-contracted outcomes.
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Affiliation(s)
- Amira El-Shal
- Department of Economics, Faculty of Economics and Political Science, Cairo University, 12613 Giza, Egypt
| | - Patricia Cubi-Molla
- Office of Health Economics, SW1E 6QT London, UK
- Department of Economics, City, University of London, EC1V 0HB London, UK
| | - Mireia Jofre-Bonet
- Office of Health Economics, SW1E 6QT London, UK
- Department of Economics, City, University of London, EC1V 0HB London, UK
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2
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Jo S, Jun DB, Park S. Impact of differential copayment on patient healthcare choice: evidence from South Korean National Cohort Study. BMJ Open 2021; 11:e044549. [PMID: 34162638 PMCID: PMC8231052 DOI: 10.1136/bmjopen-2020-044549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We evaluate the effectiveness of mild disease differential copayment policy aimed at reducing unnecessary patient visits to secondary/tertiary healthcare institutions in South Korea. DESIGN Retrospective study using difference-in-difference design. SETTING Sample Research database provided by the Korean National Health Insurance Service, between 2010 and 2013. PARTICIPANTS 206 947 patients who visited healthcare institutions to treat mild diseases during the sample period. METHODS A linear probability model with difference-in-difference approach was adopted to estimate the changes in patients' healthcare choices associated with the differential copayment policy. The dependent variable was a binary variable denoting whether a patient visited primary healthcare or secondary/tertiary healthcare to treat her/his mild disease. Patients' individual characteristics were controlled with a fixed effect. RESULTS We observed significant decrease in the proportion of patients choosing secondary/tertiary healthcare over primary healthcare by 2.99 per cent point. The decrease associated with the policy was smaller by 14% in the low-income group compared with richer population, greater by 19% among the residents of Seoul metropolitan area than among people living elsewhere, and greater among frequent healthcare visitors by 33% than among people who less frequently visit healthcare. CONCLUSION The mild disease differential copayment policy of South Korea was successful in discouraging unnecessary visits to secondary/tertiary healthcare institutions to treat mild diseases that can be treated well in primary healthcare.
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Affiliation(s)
- Sangkyun Jo
- College of Business, KAIST, Seoul, South Korea
| | - Duk Bin Jun
- College of Business, KAIST, Seoul, South Korea
| | - Sungho Park
- SNU Business School, Seoul National University, Seoul, South Korea
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AlRuthia Y, Abdulaziz Bin Aydan N, Sulaiman Alorf N, Asiri Y. How can Saudi Arabia reform its public hospital payment models? A narrative review. Saudi Pharm J 2020; 28:1520-1525. [PMID: 33041625 PMCID: PMC7537664 DOI: 10.1016/j.jsps.2020.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/27/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The cost of Saudi healthcare continues to rise at an alarming rate, putting the sustainability of the public healthcare system into question. Data have shown that hospital and healthcare providers' services represent the bulk of this rising cost, which makes the calls to reform the Saudi healthcare system more focused on payment models than at any time before. OBJECTIVE The aim of this paper is to review various identified payment models that can be used to contain costs and improve the quality of the care provided. METHOD A literature review of articles addressing the issues of cost containment and improving the quality of healthcare by reforming the current Saudi healthcare payment policy were identified through the Ovid®, Medline, and Google® Scholar search engines. RESULTS AND CONCLUSIONS Many research articles and literature reviews have identified and discussed different models of healthcare payments. Some articles have focused on one payment model, while others have discussed different payment models that have been identified. There is an urgent need to reform the current system of healthcare payments to improve the quality of healthcare and maintain funding for universal healthcare coverage in the future. Future healthcare payment reforms should consider restructuring the current healthcare system, which is largely fragmented by providing incentives to different governmental healthcare sectors, in order to transform it into a more organized and coordinated system. Thus far, there is not a single payment model that can, by itself, reduce healthcare costs and improve healthcare quality. Future healthcare reforms should use a mixture of different payment models to pay hospitals and physicians.
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Affiliation(s)
- Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Nora Sulaiman Alorf
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Yousif Asiri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Chown J. Financial Incentives and Professionals’ Work Tasks: The Moderating Effects of Jurisdictional Dominance and Prominence. ORGANIZATION SCIENCE 2020. [DOI: 10.1287/orsc.2019.1334] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This research addresses the important question of how organizations can use financial incentives to influence the work tasks of their professional workforce—a constituency that is notoriously difficult to manage because of their specialized knowledge, considerable autonomy, strong socialization, and powerful professional norms. In particular, I explore how a baseline incentive effect is moderated by two features of professionals’ tasks and jurisdictions: jurisdictional dominance (i.e., how much the profession controls the provision of the task relative to other professions) and jurisdictional prominence (i.e., how commonly provided the task is within a profession relative to other tasks). Using data on thousands of physician tasks from Ontario, Canada, and a difference-in-differences empirical design, I find that professionals’ incentive responses are smaller when a profession has higher jurisdictional dominance over a task, but are larger when the task has higher jurisdictional prominence within the profession. This research contributes to the literature on professions and professionals in multiple ways. First, I introduce the concepts of jurisdictional dominance and jurisdictional prominence, distinguishing them from each other and from existing conceptions of professional control. Second, this study shows that financial incentives can be an effective tool for influencing professionals, but highlights that their efficacy is shaped by a task’s jurisdictional dominance and jurisdictional prominence. Finally, I show that these new conceptions of jurisdictional control influence professionals’ behaviors in meaningful ways and should therefore be considered in future studies of professions.
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Affiliation(s)
- Jillian Chown
- Kellogg School of Management, Northwestern University, Evanston, Illinois 60208
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5
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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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Carroll C, Chernew M, Fendrick AM, Thompson J, Rose S. Effects of episode-based payment on health care spending and utilization: Evidence from perinatal care in Arkansas. JOURNAL OF HEALTH ECONOMICS 2018; 61:47-62. [PMID: 30059822 DOI: 10.1016/j.jhealeco.2018.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/10/2018] [Accepted: 06/20/2018] [Indexed: 06/08/2023]
Abstract
We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.
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Affiliation(s)
- Caitlin Carroll
- Department of Health Care Policy, Harvard University, 180 Longwood Ave, Boston, MA 02115, United States.
| | - Michael Chernew
- Department of Health Care Policy, Harvard University, 180 Longwood Ave, Boston, MA 02115, United States
| | - A Mark Fendrick
- University of Michigan, 2800 Plymouth Road, Building 16/Floor 4, Ann Arbor, MI 48109, United States
| | - Joe Thompson
- Arkansas Center for Health Improvement, 1401 W Capitol Ave, Victory Building, Suite 300, Little Rock, AR 72201, United States
| | - Sherri Rose
- Department of Health Care Policy, Harvard University, 180 Longwood Ave, Boston, MA 02115, United States
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7
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Beckert W. Choice in the presence of experts: The role of general practitioners in patients' hospital choice. JOURNAL OF HEALTH ECONOMICS 2018; 60:98-117. [PMID: 29957473 DOI: 10.1016/j.jhealeco.2018.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/27/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
This paper considers the micro-econometric analysis of patients' hospital choice for elective medical procedures when their choice set is pre-selected by a general practitioner (GP). GPs have a dual role with regard to elective referrals in the English NHS, advising patients and at the same time taking account of the financial implications of referral decisions on local health budgets. The paper proposes a two-stage choice model that encompasses both patient and GP level optimization. It demonstrates that estimators that do not take account of strategic pre-selection of choice sets may be biased and inconsistent. We find that GPs as patients' agents select choice options based on quality, but as agents of health authorities also consider financial implications of referrals. When considering these choice options, patients focus on tangible hospital attributes, like amenities.
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8
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Craig P, Gibson M, Campbell M, Popham F, Katikireddi SV. Making the most of natural experiments: What can studies of the withdrawal of public health interventions offer? Prev Med 2018; 108:17-22. [PMID: 29288780 PMCID: PMC6711756 DOI: 10.1016/j.ypmed.2017.12.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/23/2017] [Accepted: 12/23/2017] [Indexed: 11/25/2022]
Abstract
Many interventions that may have large impacts on health and health inequalities, such as social and public health policies and health system reforms, are not amenable to evaluation using randomised controlled trials. The United Kingdom Medical Research Council's guidance on the evaluation of natural experiments draws attention to the need for ingenuity to identify interventions which can be robustly studied as they occur, and without experimental manipulation. Studies of intervention withdrawal may usefully widen the range of interventions that can be evaluated, allowing some interventions and policies, such as those that have developed piecemeal over a long period, to be evaluated for the first time. In particular, sudden removal may allow a more robust assessment of an intervention's long-term impact by minimising 'learning effects'. Interpreting changes that follow withdrawal as evidence of the impact of an intervention assumes that the effect is reversible and this assumption must be carefully justified. Otherwise, withdrawal-based studies suffer similar threats to validity as intervention studies. These threats should be addressed using recognised approaches, including appropriate choice of comparators, detailed understanding of the change processes at work, careful specification of research questions, and the use of falsification tests and other methods for strengthening causal attribution. Evaluating intervention withdrawal provides opportunities to answer important questions about effectiveness of population health interventions, and to study the social determinants of health. Researchers, policymakers and practitioners should be alert to the opportunities provided by the withdrawal of interventions, but also aware of the pitfalls.
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Affiliation(s)
- Peter Craig
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, UK..
| | - Marcia Gibson
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, UK..
| | - Mhairi Campbell
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, UK..
| | - Frank Popham
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, UK..
| | - Srinivasa Vittal Katikireddi
- MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Top floor, 200 Renfield Street, Glasgow G2 3QB, UK..
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9
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Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance. Soc Sci Med 2017; 233:272-280. [PMID: 29548564 DOI: 10.1016/j.socscimed.2017.11.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 11/11/2017] [Accepted: 11/14/2017] [Indexed: 11/21/2022]
Abstract
As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwan's National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwan's. Our analyses show that as a single payer, Taiwan's NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHI's total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHI's advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwan's NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwan's NHI may risk compromising the equity it has achieved in the past two decades.
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10
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Lopez Bernal JA, Lu CY, Gasparrini A, Cummins S, Wharham JF, Soumerai SB. Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis. PLoS Med 2017; 14:e1002427. [PMID: 29135978 PMCID: PMC5685471 DOI: 10.1371/journal.pmed.1002427] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 10/05/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits. METHODS AND FINDINGS We conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%-1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%-2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were -0.2% (95% CI -0.6%-0.2%; p = 0.257), -0.2% (95% CI -0.6%-0.1%; p = 0.235), and 0.0% (95% CI -0.5%-0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen. CONCLUSIONS Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.
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Affiliation(s)
- James A. Lopez Bernal
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Christine Y. Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Antonio Gasparrini
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Steven Cummins
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - J. Frank Wharham
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
| | - Steven B. Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America
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11
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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: 10] [Impact Index Per Article: 1.4] [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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12
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Chalkley M, McCormick B, Anderson R, Aragon MJ, Nessa N, Nicodemo C, Redding S, Wittenberg R. Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.ObjectivesThis project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.ResultsIt appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.ConclusionsFurther work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Barry McCormick
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Robert Anderson
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | | | - Nazma Nessa
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
- Department for Business, Innovation and Skills, London, UK
| | - Catia Nicodemo
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Stuart Redding
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Raphael Wittenberg
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
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13
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Cui D, Liu X, Hawkey P, Li H, Wang Q, Mao Z, Sun J. Use of and microbial resistance to antibiotics in China: a path to reducing antimicrobial resistance. J Int Med Res 2017; 45:1768-1778. [PMID: 29239248 PMCID: PMC5805194 DOI: 10.1177/0300060516686230] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We analyzed China's current use of and microbial resistance to antibiotics, and possible means of reducing antimicrobial resistance. Interventions like executive orders within clinical settings and educational approach with vertical approaches rather than an integrated strategy to curb the use of antimicrobials remain limited. An underlying problem is the system of incentives that has resulted in the intensification of inappropriate use by health professionals and patients. There is an urgent need to explore the relationship between financial and non-financial incentives for providers and patients, to eliminate inappropriate incentives. China's national health reforms have created an opportunity to contain inappropriate use of antibiotics through more comprehensive and integrated strategies. Containment of microbial resistance may be achieved by strengthening surveillance at national, regional and hospital levels; eliminating detrimental incentives within the health system; and changing prescribing behaviors to a wider health systems approach, to achieve long-term, equitable and sustainable results and coordinate stakeholders' actions through transparent sharing of information.
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Affiliation(s)
- Dan Cui
- 1 School of Public Health, Global Health Institute, Wuhan University, China
| | - Xinliang Liu
- 1 School of Public Health, Global Health Institute, Wuhan University, China
| | - Peter Hawkey
- 2 School of Biosciences, School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - Hao Li
- 1 School of Public Health, Global Health Institute, Wuhan University, China
| | - Quan Wang
- 1 School of Public Health, Global Health Institute, Wuhan University, China
| | - Zongfu Mao
- 1 School of Public Health, Global Health Institute, Wuhan University, China
| | - Jing Sun
- 3 School of Public Health, Chinese Academy of Medical Sciences, Peking Union Medical College, China
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Craig P, Katikireddi SV, Leyland A, Popham F. Natural Experiments: An Overview of Methods, Approaches, and Contributions to Public Health Intervention Research. Annu Rev Public Health 2017; 38:39-56. [PMID: 28125392 PMCID: PMC6485604 DOI: 10.1146/annurev-publhealth-031816-044327] [Citation(s) in RCA: 248] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Population health interventions are essential to reduce health inequalities and tackle other public health priorities, but they are not always amenable to experimental manipulation. Natural experiment (NE) approaches are attracting growing interest as a way of providing evidence in such circumstances. One key challenge in evaluating NEs is selective exposure to the intervention. Studies should be based on a clear theoretical understanding of the processes that determine exposure. Even if the observed effects are large and rapidly follow implementation, confidence in attributing these effects to the intervention can be improved by carefully considering alternative explanations. Causal inference can be strengthened by including additional design features alongside the principal method of effect estimation. NE studies often rely on existing (including routinely collected) data. Investment in such data sources and the infrastructure for linking exposure and outcome data is essential if the potential for such studies to inform decision making is to be realized.
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Affiliation(s)
- Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G2 3QB, United Kingdom; , , ,
| | | | - Alastair Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G2 3QB, United Kingdom; , , ,
| | - Frank Popham
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G2 3QB, United Kingdom; , , ,
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15
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Pedersen LB, Hess S, Kjær T. Asymmetric information and user orientation in general practice: Exploring the agency relationship in a best-worst scaling study. JOURNAL OF HEALTH ECONOMICS 2016; 50:115-130. [PMID: 27723469 DOI: 10.1016/j.jhealeco.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 06/06/2023]
Abstract
This study uses a best-worst scaling experiment to test whether general practitioners (GPs) act as perfect agents for the patients in the consultation; and if not, whether this is due to asymmetric information and/or other motivations than user orientation. Survey data were collected from 775 GPs and 1379 Danish citizens eliciting preferences for a consultation. Sequential models allowing for within-person preference heterogeneity and heteroskedasticity between best and worst choices were estimated. We show that GPs do not always act as perfect agents and that this non-alignment stems from GPs being both unable and unwilling to do so. Unable since GPs have imperfect information about patients' preferences, and unwilling since they are also motivated by other factors than user orientation. Our findings highlight the need for multi-pronged strategies targeting different motivational factors to ensure that GPs act in correspondence with patients' preferences in areas where alignment is warranted.
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Affiliation(s)
- Line Bjørnskov Pedersen
- Centre of Health Economics Research (COHERE), Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark; Research Unit for General Practice, University of Southern Denmark, J.B. Winsløwsvej 9A, 1, 5000 Odense C, Denmark.
| | - Stephane Hess
- Institute for Transport Studies & Choice Modelling Centre, University of Leeds, Lifton Villas, 1-3 Lifton Place, Leeds LS2 9JT, UK
| | - Trine Kjær
- Centre of Health Economics Research (COHERE), Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
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Kantarevic J, Kralj B. Physician Payment Contracts in the Presence of Moral Hazard and Adverse Selection: The Theory and Its Application in Ontario. HEALTH ECONOMICS 2016; 25:1326-40. [PMID: 26239311 DOI: 10.1002/hec.3220] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 06/23/2015] [Accepted: 06/29/2015] [Indexed: 05/25/2023]
Abstract
We develop a stylized principal-agent model with moral hazard and adverse selection to provide a unified framework for understanding some of the most salient features of the recent physician payment reform in Ontario and its impact on physician behavior. These features include the following: (i) physicians can choose a payment contract from a menu that includes an enhanced fee-for-service contract and a blended capitation contract; (ii) the capitation rate is higher, and the cost-reimbursement rate is lower in the blended capitation contract; (iii) physicians sort selectively into the contracts based on their preferences; and (iv) physicians in the blended capitation model provide fewer services than physicians in the enhanced fee-for-service model. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jasmin Kantarevic
- Ontario Medical Association, Toronto, Canada
- Canadian Centre for Health Economics, Toronto, Canada
- Institute for Labor Studies, Bonn, Germany
- University of Toronto, Toronto, Canada
| | - Boris Kralj
- Ontario Medical Association, Toronto, Canada
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Dolton P, Pathania V. Can increased primary care access reduce demand for emergency care? Evidence from England's 7-day GP opening. JOURNAL OF HEALTH ECONOMICS 2016; 49:193-208. [PMID: 27395472 DOI: 10.1016/j.jhealeco.2016.05.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 06/06/2023]
Abstract
Restricted access to primary care can lead to avoidable, excessive use of expensive emergency care. Since 2013, partly to alleviate overcrowding at the Accident & Emergency (A&E) units of hospitals, the UK has been piloting 7-day opening of General Practitioner (GP) practices to improve primary care access for patients. We evaluate the impact of these pilots on patient attendances at A&E. We estimate that 7-day GP opening has reduced A&E attendances by patients of pilot practices by 9.9% with most of the impact on weekends which see A&E attendances fall by 17.9%. The effect is non-monotonic in case severity with most of the fall occurring in cases of moderate severity. An additional finding is that there is also a 9.9% fall in weekend hospital admissions (from A&E) which is entirely driven by a fall in admissions of elderly patients. The impact on A&E attendances appears to be bigger among wealthier patients. We present evidence in support of a causal interpretation of our results and discuss policy implications.
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Affiliation(s)
- Peter Dolton
- Department of Economics, University of Sussex, United Kingdom; CEP, LSE, United Kingdom.
| | - Vikram Pathania
- Department of Economics, University of Sussex, United Kingdom.
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18
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Riise J, Hole AR, Gyrd-Hansen D, Skåtun D. GPs' implicit prioritization through clinical choices - evidence from three national health services. JOURNAL OF HEALTH ECONOMICS 2016; 49:169-83. [PMID: 27476007 DOI: 10.1016/j.jhealeco.2016.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 07/01/2016] [Accepted: 07/02/2016] [Indexed: 05/27/2023]
Abstract
We present results from an extensive discrete choice experiment, which was conducted in three countries (Norway, Scotland, and England) with the aim of disclosing stated prescription behaviour in different decision making contexts and across different cost containment cultures. We show that GPs in all countries respond to information about societal costs, benefits and effectiveness, and that they make trade-offs between them. The UK GPs have higher willingness to accept costs when they can prescribe medicines that are cheaper or more preferred by the patient, while Norwegian GPs tend to have higher willingness to accept costs for attributes regarding effectiveness or the doctors' experience. In general, there is a substantial amount of heterogeneity also within each country. We discuss the results from the DCE in the light of the GPs' two conflicting agency roles and what we know about the incentive structures and cultures in the different countries.
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Affiliation(s)
- Julie Riise
- Department of Economics, University of Bergen, Postbox 7800, 5020 Beregen, Norway.
| | - Arne Risa Hole
- Department of Economics, The University of Sheffield, 9 Mappin Street, Sheffield S1 4DT, UK
| | - Dorte Gyrd-Hansen
- COHERE, Department of Business and Economics, University of Southern Denmark; COHERE, Department of Public Health, University of Southern Denmark; Department of Community Medicine, UiT, The Arctic University of Norway
| | - Diane Skåtun
- Health Economics Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK
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Iversen T, Mokienko A. Supplementing gatekeeping with a revenue scheme for secondary care providers. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2016; 16:247-267. [PMID: 27878675 DOI: 10.1007/s10754-016-9188-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/11/2016] [Indexed: 06/06/2023]
Abstract
We study implications of a change in the payment scheme for radiology providers in Norway that was implemented in 2008. The change implies reduced fee-for-service and increased fixed budget for a contracted volume of services. A consequence of the change is that private providers have less incentive to conduct examinations beyond the contracted volume. Different from the situation observed before the change in 2008, the volume is no longer determined by the demand side, and a rationing of the supply occurs. We employ data on radiological examinations initiated by GPs' referrals. We apply monthly data at the physician-practice level for 2007-2010. The data set is unique because it includes information about all GPs in the Norwegian patient-list system. The results indicate that private providers conducted fewer examinations in 2008-2010 compared with previous periods and that public hospitals did either the same volume or more. We find that GPs who operate in a more competitive environment experienced a greater reduction in magnetic resonance imaging, both performed by private providers and in total for their patients. We argue that this result supports a hypothesis that patients with lower expected benefits are rationed. Hence, rationing from the supply side might supplement GP gatekeeping.
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Affiliation(s)
- Tor Iversen
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway.
| | - Anastasia Mokienko
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, 0317, Oslo, Norway
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Gardner K, Davies GP, Edwards K, McDonald J, Findlay T, Kearns R, Joshi C, Harris M. A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy. Aust J Prim Health 2016; 22:40-49. [DOI: 10.1071/py15148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/04/2015] [Indexed: 11/23/2022]
Abstract
The aim of this systematic review was to assess evidence of the impact of commissioning on health service use, quality, outcomes and value for money and to consider findings in the Australian context. Systematic searches of the literature identified 444 papers and, after exclusions, 36 were subject to full review. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis and impacts were assessed at individual, subpopulation and population levels. Little evidence of the effectiveness of commissioning at any level was available and observed impacts were highly context-dependent. There was insufficient evidence to identify a preferred model. Lack of skills and capacity were cited as major barriers to the implementation of commissioning. Successful commissioning requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Engagement of consumers and providers, especially physicians, was considered to be critically important but is time consuming and has proven difficult to sustain. Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, and for contracting and monitoring performance. Lack of information resulted in serious problems. High-quality nationally standardised performance measures and data requirements need to be built into contracts and ongoing monitoring and evaluation. In Australia, there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning.
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Hayen AP, van den Berg MJ, Meijboom BR, Struijs JN, Westert GP. Incorporating shared savings programs into primary care: from theory to practice. BMC Health Serv Res 2015; 15:580. [PMID: 26715151 PMCID: PMC4696086 DOI: 10.1186/s12913-015-1250-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/19/2015] [Indexed: 11/30/2022] Open
Abstract
Background In several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted. Methods Based on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark. Results The minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size. Conclusion Shared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1250-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arthur P Hayen
- Tilburg School of Social and Behavioral Sciences, dpt. Tranzo (Scientific center for care and welfare), Tilburg University, Address: PO Box 90153, 5000, Tilburg, LE, The Netherlands. .,National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Address: PO Box, 3720, Bilthoven, BA, The Netherlands.
| | - Michael J van den Berg
- National Institute for Public Health and the Environment, Centre for Health and Society, Address: PO Box 1, 3720, Bilthoven, BA, The Netherlands.
| | - Bert R Meijboom
- Tilburg School of Economics and Management, dpt. CentER (Center for Economic Research), Tilburg University, Address: PO Box 90153, 5000, Tilburg, LE, The Netherlands.
| | - Jeroen N Struijs
- National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Address: PO Box, 3720, Bilthoven, BA, The Netherlands.
| | - Gert P Westert
- IQ Healthcare (Scientific Institute for Quality of Healthcare), Radboud University Medical Center, Address: PO Box 9101, 114, 6500, Nijmegen, HB, The Netherlands.
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22
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Sun J, Zhang X, Zhang Z, Wagner AK, Ross-Degnan D, Hogerzeil HV. Impacts of a new insurance benefit with capitated provider payment on healthcare utilization, expenditure and quality of medication prescribing in China. Trop Med Int Health 2015; 21:263-74. [PMID: 26555238 DOI: 10.1111/tmi.12636] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess a new Chinese insurance benefit with capitated provider payment for common diseases in outpatients. METHODS Longitudinal health insurance claims data, health administrative data and primary care facility data were used to assess trajectories in outpatient visits, inpatient admissions, expenditure per common disease outpatient (CD/OP) visit and prescribing indicators over time. We conducted segmented regression analyses of interrupted time series data to measure changes in level and trend overtime, and cross-sectional comparisons against external standards. RESULTS The number of total outpatient visits at 46 primary care facilities (on the CD/OP benefit as of July 2012) increased by 46 895 visits/month (P = 0.004, 95% CI: 15 795-77 994); the average number of CD/OP visits reached 1.84/year/enrollee in 2012; monthly inpatient admissions dropped from 6.4 (2009) to 4.3 (2012) per 1000 enrollees; the median total expenditure per CD/OP visit dropped by CNY 15.40 (P = 0.16, 95% CI: -36.95~6.15); injectable use dropped by 7.38% (P = 0.03, 95% CI: -14.08%~-0.68%); antibiotic use was not improved. CONCLUSIONS Zhuhai's new CD/OP benefit with capitated provider payment has expanded access to primary care, which may have led to a reduction in expensive specialist inpatient services for CD/OP benefit enrollees. Cost awareness was likely raised, and rapidly growing expenditures were contained. Although having been partially improved, inappropriate prescribing of antibiotics and injectables was still prevalent. More explicit incentives and specific quality of care targets must be incorporated into the capitated provider payment to promote scientifically sound and cost-effective care and treatment.
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Affiliation(s)
- Jing Sun
- Department of Nutrition, Food and Drug Safety, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, P.R.China
| | - Xiaotian Zhang
- Zhuhai Health Insurance Research Association, Zhuhai, Guangdong, P.R.China
| | - Zou Zhang
- Department of Management, Beijing Normal University, Zhuhai, Guangdong, P.R.China
| | - Anita K Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Hans V Hogerzeil
- Department of Health Sciences, University Medical Centre Groningen, Groningen, The Netherlands
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Miller R, Peckham S, Coleman A, McDermott I, Harrison S, Checkland K. What happens when GPs engage in commissioning? Two decades of experience in the English NHS. J Health Serv Res Policy 2015; 21:126-33. [PMID: 26158276 DOI: 10.1177/1355819615594825] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. METHODS A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. RESULTS The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with 'virtuous cycles' (experience of being able to make changes feeding back to encourage greater engagement) and 'vicious cycles' (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. CONCLUSION Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.
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Affiliation(s)
- Rosalind Miller
- PhD Student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Stephen Peckham
- Professor of Health Policy, Centre for Health Services Studies, University of Kent, UK
| | - Anna Coleman
- Research Fellow, Centre for Primary Care, University of Manchester, UK
| | - Imelda McDermott
- Research Associate, Centre for Primary Care, University of Manchester, UK
| | - Stephen Harrison
- Professor of Social Policy, Centre for Primary Care, University of Manchester, UK
| | - Kath Checkland
- Reader in Health Policy and Primary Care, Centre for Primary Care, University of Manchester, UK
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24
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Rischatsch M. Who joins the network? Physicians' resistance to take budgetary co-responsibility. JOURNAL OF HEALTH ECONOMICS 2015; 40:109-121. [PMID: 25637711 DOI: 10.1016/j.jhealeco.2014.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 12/01/2014] [Accepted: 12/06/2014] [Indexed: 06/04/2023]
Abstract
Managed Care (MC) is expected to provide health care at a lower cost than conventional provision. Therefore, Switzerland intends to promote MC by forcing health insurers to write MC contracts and introducing budgetary co-responsibility for ambulatory care physicians. A discrete choice experiment conducted in 2011 including 872 physicians reveals a strong preference heterogeneity with respect to network participation and alternative remuneration schemes. The number of physicians working in networks is unlikely to rise on a voluntary basis, while general practitioners are more likely to join networks than specialists with surgical activities. For physicians considering joining networks, cost savings are predicted to be higher than the estimated willingness-to-accept payments.
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25
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Sheaff R, Charles N, Mahon A, Chambers N, Morando V, Exworthy M, Byng R, Mannion R, Llewellyn S. NHS commissioning practice and health system governance: a mixed-methods realistic evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundBy 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).ObjectivesTo: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.DesignMixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.ResultsIn the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.ConclusionsCommissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | - Nigel Charles
- School of Government, Plymouth University, Plymouth, UK
| | - Ann Mahon
- Manchester Business School, Manchester University, Manchester, UK
| | - Naomi Chambers
- Manchester Business School, Manchester University, Manchester, UK
| | | | | | - Richard Byng
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Sue Llewellyn
- Manchester Business School, Manchester University, Manchester, UK
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Ryan AM, Burgess JF, Dimick JB. Why We Should Not Be Indifferent to Specification Choices for Difference-in-Differences. Health Serv Res 2014; 50:1211-35. [PMID: 25495529 DOI: 10.1111/1475-6773.12270] [Citation(s) in RCA: 171] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To evaluate the effects of specification choices on the accuracy of estimates in difference-in-differences (DID) models. DATA SOURCES Process-of-care quality data from Hospital Compare between 2003 and 2009. STUDY DESIGN We performed a Monte Carlo simulation experiment to estimate the effect of an imaginary policy on quality. The experiment was performed for three different scenarios in which the probability of treatment was (1) unrelated to pre-intervention performance; (2) positively correlated with pre-intervention levels of performance; and (3) positively correlated with pre-intervention trends in performance. We estimated alternative DID models that varied with respect to the choice of data intervals, the comparison group, and the method of obtaining inference. We assessed estimator bias as the mean absolute deviation between estimated program effects and their true value. We evaluated the accuracy of inferences through statistical power and rates of false rejection of the null hypothesis. PRINCIPAL FINDINGS Performance of alternative specifications varied dramatically when the probability of treatment was correlated with pre-intervention levels or trends. In these cases, propensity score matching resulted in much more accurate point estimates. The use of permutation tests resulted in lower false rejection rates for the highly biased estimators, but the use of clustered standard errors resulted in slightly lower false rejection rates for the matching estimators. CONCLUSIONS When treatment and comparison groups differed on pre-intervention levels or trends, our results supported specifications for DID models that include matching for more accurate point estimates and models using clustered standard errors or permutation tests for better inference. Based on our findings, we propose a checklist for DID analysis.
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Affiliation(s)
- Andrew M Ryan
- University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI
| | - James F Burgess
- Veterans Affairs Boston Health Care System, US Department of Veteran Affairs, Boston University School of Public Health, Boston, MA
| | - Justin B Dimick
- Department of Surgery, School of Medicine University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Marton J, Yelowitz A, Talbert JC. A tale of two cities? The heterogeneous impact of Medicaid managed care. JOURNAL OF HEALTH ECONOMICS 2014; 36:47-68. [PMID: 24747920 DOI: 10.1016/j.jhealeco.2014.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 02/23/2014] [Accepted: 03/04/2014] [Indexed: 06/03/2023]
Abstract
Evaluating Accountable Care Organizations is difficult because there is a great deal of heterogeneity in terms of their reimbursement incentives and other programmatic features. We examine how variation in reimbursement incentives and administration among two Medicaid managed care plans impacts utilization and spending. We use a quasi-experimental approach exploiting the timing and county-specific implementation of Medicaid managed care mandates in two contiguous regions of Kentucky. We find large differences in the relative success of each plan in reducing utilization and spending that are likely driven by important differences in plan design. The plan that capitated primary care physicians and contracted out many administrative responsibilities to an experienced managed care organization achieved significant reductions in outpatient and professional utilization. The plan that opted for a fee-for-service reimbursement scheme with a group withhold and handled administration internally saw a much more modest reduction in outpatient utilization and an increase in professional utilization.
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Affiliation(s)
- James Marton
- Department of Economics and Georgia Health Policy Center, Andrew Young School of Policy Studies, Georgia State University, United States.
| | - Aaron Yelowitz
- Department of Economics, University of Kentucky, United States.
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Schmitz H. Practice budgets and the patient mix of physicians - the effect of a remuneration system reform on health care utilisation. JOURNAL OF HEALTH ECONOMICS 2013; 32:1240-1249. [PMID: 24211757 DOI: 10.1016/j.jhealeco.2013.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 07/23/2013] [Accepted: 09/15/2013] [Indexed: 06/02/2023]
Abstract
This study analyses the effect of a change in the remuneration system for physicians on the treatment lengths as measured by the number of doctor visits using data from the German Socio-Economic Panel over the period 1995-2002. Specifically, I analyse the introduction of a remuneration cap (so called practice budgets) for physicians who treat publicly insured patients in 1997. I find evidence that the reform of 1997 did not change the extensive margin of doctor visits but strongly affected the intensive margin. The conditional number of doctor visits among publicly insured decreased while it increased among privately insured. This can be seen as evidence that physicians respond to the change in incentives induced by the reform by altering their patient mix.
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Markussen S, Røed K, Røgeberg O. The changing of the guards: can family doctors contain worker absenteeism? JOURNAL OF HEALTH ECONOMICS 2013; 32:1230-1239. [PMID: 24215740 DOI: 10.1016/j.jhealeco.2013.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 06/02/2023]
Abstract
Using administrative data from Norway, we examine the extent to which family doctors influence their clients' propensity to claim sick-pay. The analysis exploits exogenous switches of family doctors occurring when physicians quit, retire, or for other reasons sell their patient lists. We find that family doctors have significant influence on their clients' absence behavior, particularly on absence duration. Their influence is stronger in geographical areas with weaker competition between physicians. We conclude that it is possible for family doctors to contain sick-pay expenditures to some extent, and that there is a considerable variation in the way they perform this task.
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30
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Olsen KR, Gyrd-Hansen D, Sørensen TH, Kristensen T, Vedsted P, Street A. Organisational determinants of production and efficiency in general practice: a population-based study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:267-76. [PMID: 22143360 DOI: 10.1007/s10198-011-0368-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 11/21/2011] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Shortage of general practitioners (GPs) and an increased political focus on primary care have enforced the interest in efficiency analysis in the Danish primary care sector. This paper assesses the association between organisational factors of general practices and production and efficiency. METHODS We assume that production and efficiency can be modelled using a behavioural production function. We apply the Battese and Coelli (Empir Econ 20:325-332, 1995) estimator to accomplish a decomposition of exogenous variables to determine the production frontier and variables determining the individual GPs distance to this frontier. Two different measures of practice outputs (number of office visits and total production) were applied and the results compared. RESULTS The results indicate that nurses do not substitute GPs in the production. The production function exhibited constant returns to scale. The mean level of efficiency was between 0.79 and 0.84, and list size was the most important determinant of variation in efficiency levels. CONCLUSIONS Nurses are currently undertaking other tasks than GPs, and larger practices do not lead to increased production per GP. However, a relative increase in list size increased the efficiency. This indicates that organisational changes aiming to increase capacity in general practice should be carefully designed and tested.
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Affiliation(s)
- Kim Rose Olsen
- Danish Institute for Health Services Research, Copenhagen, Denmark.
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31
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GPs and hospital expenditures. Should we keep expenditure containment programs alive? Soc Sci Med 2013; 82:10-20. [DOI: 10.1016/j.socscimed.2013.01.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 12/18/2012] [Accepted: 01/21/2013] [Indexed: 11/23/2022]
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32
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Olsen KR. Patient complexity and GPs' income under mixed remuneration. HEALTH ECONOMICS 2012; 21:619-632. [PMID: 21484937 DOI: 10.1002/hec.1731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 02/20/2011] [Accepted: 03/02/2011] [Indexed: 05/30/2023]
Abstract
Because of problems with recruiting GPs to deprived areas in Denmark, it has been discussed whether the mixed remuneration scheme is flexible enough to compensate GPs serving patients with high need for services. The objective is to assess how patient heterogeneity affects list size, income and total utility of GPs operating under a mixed remuneration scheme. We adapt the model by Iversen (2004) as a theoretical framework for analysing the consequences of patient heterogeneity in a mixed remuneration system. We use a data set of Danish solo practitioners to analyse the effect of patient complexity on list size and income. From the theoretical model we find that higher levels of patient complexity lead GPs to choose a lower list size, whereas the effect on income is ambiguous. The effect on total utility (income and leisure) is, however, shown to be negative. Using empirical data from 1039 solo practices we find that patient complexity reduces both list size and income and conclude that a mixed per capita and fee for service remuneration system does not fully compensate practices with more complex patients. Differentiated per capita payment may represent a means of ensuring fair and equal income of GPs.
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Affiliation(s)
- K R Olsen
- The Research Unit of Health Economics, University of Southern Denmark, Odense, Denmark.
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34
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Market conditions and general practitioners' referrals. ACTA ACUST UNITED AC 2011; 11:245-65. [PMID: 22009482 DOI: 10.1007/s10754-011-9101-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 10/04/2011] [Indexed: 10/16/2022]
Abstract
We study how market conditions influence referrals of patients by general practitioners (GPs). We set up a model of GP referral for the Norwegian health care system, where a GP receives capitation payment based on the number of patients in his practice, as well as fee-for-service reimbursements. A GP may accept new patients or close the practice to new patients. We model GPs as partially altruistic, and compete for patients. We show that a GP operating in a more competitive market has a higher referral rate. To compete for patients and to retain them, a GP satisfies patients' requests for referrals. Furthermore, a GP who faces a patient shortage will refer more often than a GP who does not. Tests with Norwegian GP radiology referral data support our theory.
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35
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Pritchard DA. Prepaid coordinated care for patients with diabetes: practices and patients bear the risks. Med J Aust 2011; 194:599-601. [DOI: 10.5694/j.1326-5377.2011.tb03114.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 03/02/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Douglas A Pritchard
- Discipline of General Practice, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, WA
- Lockridge Medical Centre, Perth, WA
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36
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Wranik D, Durier-Copp M. Framework for the design of physician remuneration methods in primary health care. SOCIAL WORK IN PUBLIC HEALTH 2011; 26:231-259. [PMID: 21534123 DOI: 10.1080/19371911003748968] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Economists have generated a large body of theoretical and empirical knowledge with respect to the design of physician remuneration methods (PRM). This knowledge is difficult to use for a policy maker, because of its technical nature and its fragmentation. The article brings together the scattered elements of theory and evidence into a structured framework that adds practical use value to economic theory, useful in the applied practice of policy development, design, implementation, and evaluation. The article argues that the optimal choice of PRM depends on the goals of the health care system, and on external contextual factors. Fee-for-service payments are best when the goals are quantity of care and risk acceptance. Capitation is best when the goals are collaboration between providers and delivery of preventive services and health promotion. Salaries are best when population density is low, and the goal is to recruit physicians to rural and remote areas. Blended payment models are recommended for the achievement of multiple goals. As a demonstration of use value, the framework is applied to the assessment of Canadian PRM.
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Affiliation(s)
- Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, Nova Scotia, Canada.
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37
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Shafrin J. Operating on commission: analyzing how physician financial incentives affect surgery rates. HEALTH ECONOMICS 2010; 19:562-580. [PMID: 19399752 DOI: 10.1002/hec.1495] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This paper employs a nationally representative, household-based dataset in order to test how the compensation method of both the specialists and the primary care providers affects surgery rates. After controlling for adverse selection, I find that when specialists are paid through a fee-for-system scheme rather than on a capitation basis, surgery rates increase 78%. The impact of primary care physician compensation on surgery rates depends on whether or not referral restrictions are present.
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MESH Headings
- Adult
- Capitation Fee
- Decision Making
- Elective Surgical Procedures/economics
- Elective Surgical Procedures/statistics & numerical data
- Fee-for-Service Plans/economics
- Fee-for-Service Plans/statistics & numerical data
- Female
- Health Care Surveys
- Humans
- Insurance, Health/classification
- Insurance, Health/economics
- Male
- Patient Selection
- Physician Incentive Plans/economics
- Physician Incentive Plans/statistics & numerical data
- Physicians, Family/economics
- Physicians, Family/statistics & numerical data
- Practice Patterns, Physicians'/economics
- Practice Patterns, Physicians'/statistics & numerical data
- Referral and Consultation/economics
- Referral and Consultation/statistics & numerical data
- Specialties, Surgical/economics
- Specialties, Surgical/statistics & numerical data
- Surgical Procedures, Operative/economics
- Surgical Procedures, Operative/statistics & numerical data
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Affiliation(s)
- Jason Shafrin
- Department of Economics, University of California - San Diego, La Jolla, CA, USA.
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38
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Affiliation(s)
- Alan Maynard
- Department of Health Sciences, Hull-York Medical School, University of York, UK.
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39
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Johar M. The effect of a public health card program on the supply of health care. Soc Sci Med 2010; 70:1527-35. [PMID: 20207463 DOI: 10.1016/j.socscimed.2010.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 11/26/2009] [Accepted: 01/20/2010] [Indexed: 11/29/2022]
Abstract
The supply-side responsiveness to public programs targeted to consumers is not widely studied. However, it is unlikely that supply variables remain constant, particularly when their link to the demand initiative is weak. The aim of this study is to provide such analysis, using the experience of the Indonesian health card program, which is a demand-sided program. Without an increase in staff or an appropriate salary revision, the salary payment system of the public sector may not adequately reward the existing health workers, lowering their incentives to maintain their public position. Using data from the Indonesian Family Life Surveys on public health centres, the leading providers of outpatient services in the public sector, this study found some evidence that the health card program resulted in a reduction in the number of full-time GPs working in these facilities. Other conditions not related to workers' compensation, such as infrastructure conditions and registration fees, were not adversely affected. Identification of this program's effect is achieved by variations in time and the intensity of health card distribution across communities. The findings highlight the importance of public policy management in general, and sheds light on physicians' behaviour in developing countries, about which we know very little.
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Affiliation(s)
- Meliyanni Johar
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, PO Box 123, Broadway, NSW 2000, Australia.
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40
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Bloor K, Maynard A. Reforming the English NHS: a continuing journey. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2010; 8:373-375. [PMID: 21043538 DOI: 10.2165/11586180-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- Karen Bloor
- Department of Health Sciences, University of York, York, UK.
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41
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Laudicella M, Cookson R, Jones AM, Rice N. Health care deprivation profiles in the measurement of inequality and inequity: an application to GP fundholding in the English NHS. JOURNAL OF HEALTH ECONOMICS 2009; 28:1048-1061. [PMID: 19660818 DOI: 10.1016/j.jhealeco.2009.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 07/02/2009] [Accepted: 07/08/2009] [Indexed: 05/28/2023]
Abstract
This paper proposes a new approach to the measurement of inequality and inequity in the delivery of health care based on contributions from the literature on poverty and deprivation. This approach has some appealing characteristics: (1) inequity is additively decomposable by population subgroups; (2) the approach does not rely on socio-economic ranks; (3) it provides a graphical representation of the distribution of inequity; (4) it offers a range of indices consistent with dominance. An empirical application is provided investigating the effect of the GP fundholding reform on equity in English NHS. The results show that the most equitable GP practices self-selected into the scheme in 1991; evidence of an inequity-reducing treatment effect as well as a self-selection effect are found in 1992 and 1993; the self-selection process reduces and no evidence of a treatment effect is present thereafter.
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42
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Granlund D. Are private physicians more likely to veto generic substitution of prescribed pharmaceuticals? Soc Sci Med 2009; 69:1643-50. [PMID: 19815322 DOI: 10.1016/j.socscimed.2009.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Indexed: 11/28/2022]
Abstract
Physicians' decisions whether or not to veto generic substitution were analyzed using a sample of 350,000 pharmaceutical prescriptions from the county of Västerbotten, Sweden. Although generic substitution reforms have been introduced in many European countries and American states, this is to my knowledge the first study on this topic. The topic is important since physicians' decisions regarding generic substitution not only directly affect patients' and insurers' costs for pharmaceuticals, but also indirectly since more bans against substitution reduces price-competition between pharmaceutical firms. The primary purpose was to test if physicians working at private practices were more likely to oppose substitution than county-employed physicians working on salary. It was found that private physicians were 50-80% more likely to veto substitution. Also, the probability of a veto was found to increase as patients' copayments decreased. This might indicate moral hazard in insurance, though other explanations are plausible.
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Affiliation(s)
- David Granlund
- The Swedish Retail Institute (HUI) and Umeå University, Department of Economics, Stockholm/Umeå, Sweden.
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43
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Olsen KR, Gyrd-Hansen D, Boegh A, Hansen SH. GPs as citizens' agents: prescription behavior and altruism. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2009; 10:399-407. [PMID: 19083035 DOI: 10.1007/s10198-008-0140-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Accepted: 11/18/2008] [Indexed: 05/27/2023]
Abstract
To curb the heavily increasing drug budgets some Danish counties have introduced voluntary agreements between general practitioners (GPs) and health authorities. We extend the models of generic prescription by Hellerstein (Rand J Econ 29(1):108-136, 1998) and Lundin (J Health Econ 19:639-662, 2000) to allow for substitution between analogues and use difference-in-difference models to assess the effect on two drug groups (lipid-lowering and rheumatism drugs). For both drug groups we find evidence of a significant effect of the intervention. In the case of lipid-lowering drugs, we found a significant larger impact on GPs with low loyalty to the insurer and with indication of low prescription quality. In contrast we found that the intervention had a significantly lower impact on this group of GPs in the case of rheumatism drugs. We conclude that the effectiveness of the voluntary approach may partly be due to its indirect effect on GPs' altruistic motivation, which makes the GPs and the authorities collide in a common agency role.
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Affiliation(s)
- Kim Rose Olsen
- DSI Danish Institute for Health Services Research, Dampfaergevej 27-29, 2100 Copenhagen, Denmark.
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44
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Conrad DA, Perry L. Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It? Annu Rev Public Health 2009; 30:357-71. [DOI: 10.1146/annurev.publhealth.031308.100243] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Douglas A. Conrad
- Department of Health Services, University of Washington, Seattle, Washington 98195;
| | - Lisa Perry
- Department of Economics, University of Washington, Seattle, Washington 98195;
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45
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Gravelle H, Siciliani L. Ramsey waits: allocating public health service resources when there is rationing by waiting. JOURNAL OF HEALTH ECONOMICS 2008; 27:1143-1154. [PMID: 18468707 DOI: 10.1016/j.jhealeco.2008.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 03/11/2008] [Accepted: 03/19/2008] [Indexed: 05/26/2023]
Abstract
The optimal allocation of a public health care budget across treatments must take account of the way in which care is rationed within treatments since this will affect their marginal value. We investigate the optimal allocation rules for public health care systems where user charges are fixed and care is rationed by waiting. The optimal waiting time is higher for treatments with demands more elastic to waiting time, higher costs, lower charges, smaller marginal welfare loss from waiting by treated patients, and smaller marginal welfare losses from under-consumption of care. The results hold for a wide range of welfarist and non-welfarist objective functions and for systems in which there is also a private health care sector. They imply that allocation rules based purely on cost effectiveness ratios are suboptimal because they assume that there is no rationing within treatments.
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Affiliation(s)
- Hugh Gravelle
- National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO10 5D, UK.
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46
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Activity based financing in England: the need for continual refinement of payment by results. HEALTH ECONOMICS POLICY AND LAW 2007; 2:419-27. [DOI: 10.1017/s174413310700429x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractThe English National Health Service is introducing activity based tariff systems or Payment by Results (PbR) as the basis for hospital funding. The funding arrangements provide incentives for increasing activity, particularly day surgery, and, uniquely, are based on costing data from all hospitals. But prices should not be based on average costs and the potential of PbR to improve the quality of care is yet to be exploited. Without refinement, PbR threatens to undermine expenditure control, to divert resources away from primary care, and to distort needs based funding.
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47
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Dusheiko M, Gravelle H, Yu N, Campbell S. The impact of budgets for gatekeeping physicians on patient satisfaction: evidence from fundholding. JOURNAL OF HEALTH ECONOMICS 2007; 26:742-62. [PMID: 17276530 DOI: 10.1016/j.jhealeco.2006.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Revised: 03/13/2006] [Accepted: 12/18/2006] [Indexed: 05/13/2023]
Abstract
Between 1991 and 1998 English general practices had the option of holding budgets for prescribing and elective secondary care. Fundholding was reintroduced in 2005. We examine the effect of fundholding on patients' satisfaction with their practice, using a cross section of 4441 patients from 60 practices in the last year of fundholding (1998). We employ instrumental variables to allow for the endogeneity of fundholding. Patients of fundholders were less satisfied with the opening hours of their practice, their GP's knowledge of their medical history, with their GP's ability to arrange tests and willingness to refer to a specialist, and were more likely to agree that their doctor was more concerned about keeping costs down. Fundholder practices performed better on a number of process measures of care, and fundholding patients were more satisfied with additional non-medical services provided by the practice. The probability that patients were overall at least very satisfied with their GP practice was 0.073 (95% CI, 0.009-0.138) smaller in fundholding practices.
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Affiliation(s)
- Mark Dusheiko
- National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO10 5DD, England.
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48
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Martin S, Rice N, Jacobs R, Smith P. The market for elective surgery: joint estimation of supply and demand. JOURNAL OF HEALTH ECONOMICS 2007; 26:263-85. [PMID: 16978718 DOI: 10.1016/j.jhealeco.2006.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2004] [Revised: 08/21/2006] [Accepted: 08/21/2006] [Indexed: 05/11/2023]
Abstract
This paper develops models of the demand for and supply of elective (non-emergency) surgery using a panel of quarterly data for 200 English hospitals over the period 1995-2002. Unusually, distinct measures of supply (outpatients seen and inpatient admissions) and demand (outpatient referrals and decisions to admit) are available for each observation. These offer the opportunity to estimate separate empirical models of supply and demand using ordinary least squares (OLS) regression methods. However, the strong correlation between the residuals of these models suggests some merit in the deployment of seemingly unrelated regression (SUR) methods. Although both static and dynamic SUR estimations leave the results largely qualitatively unchanged, SUR estimation can have a considerable quantitative effect relative to the OLS results. For example, SUR estimation generates a lower elasticity of inpatient demand with respect to waiting time than that obtained via OLS. The results offer an important justification for more careful econometric modelling of hospital behaviour than has traditionally been employed in the health economics literature.
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Affiliation(s)
- Stephen Martin
- Department of Economics, University of York, Heslington, York YO10 5DD, UK.
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49
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Carlsen F, Grytten J, Kjelvik J, Skau I. Better primary physician services lead to fewer hospital admissions. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2007; 8:17-24. [PMID: 17165076 DOI: 10.1007/s10198-006-0001-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Accepted: 07/11/2006] [Indexed: 05/13/2023]
Abstract
The aim of the study was to examine whether improved quality of primary physician services, measured by patient satisfaction, leads to fewer admissions to somatic hospitals. We studied differences in hospital admissions at the municipality level in Norway. In addition to the standard explanatory variables for use of hospitals--gender, age, socio-economic status and travelling distance to the nearest hospital--we also included a measure of patient satisfaction with primary physician services in the municipality. Data on patient satisfaction was obtained from an extensive questionnaire survey of 63,798 respondents. We found a statistically significant negative relationship between patient satisfaction and the number of hospital admissions. This conclusion was robust with regard to the empirical specification, and the effect was large.
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50
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