Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting

A qualitative study of purchaser unit employees’ experiences of patient pathways from specialist healthcare to primary healthcare in Norway

Introduction

Understanding the purchaser–provider split model in the patient pathway is important. The purchaser is a key player in managing the flow between specialist and municipal healthcare services. A smoother patient transfer has been a priority in Norway, but also challenging. Accordingly, this study aims to describe and explain how the purchasers operate as liaisons during patient transfers from specialist to primary healthcare services.

Methods

Eleven interviews were conducted with employees at purchaser units in primary healthcare in Norway. The interviewees’ professional backgrounds were in nursing and physiotherapy, as well as casework, and management. The interviews took place in 2018–2019 and analyzed with Graneheim and Lundman's content analysis strategy.

Results

The interviewees’ views reflected the changes they experienced in the wake of healthcare reforms in specialist healthcare services and municipal healthcare institutions. Three themes emerged from the analyses: (1) increased efficiency requirements after the Coordination Reform, (2) better reporting systems and the need for role clarifications in contact with hospitals, and (3) the need for good assessments for safe transfer to the municipality.

Discussion

Purchaser unit employees’ experiences with patient pathways point towards a need for certain changes. There is a need for increased efficiency requirements for purchasing units, even with new electronic tools, as well as a growing need for better reporting systems and a common understanding between the service levels about what patients can expect in the municipalities.

Desirability Optimization Models to Create the Global Healthcare Competitiveness Index

The aim of this research is to enhance desirability optimization models to create a global healthcare competitiveness index (GHCI) covering 53 countries with gross domestic product per capita (GDP PC) of over $10,000. The GHCI is defined as an index that reveals the progress and quality of the healthcare systems in countries providing their patients with easier access opportunities to healthcare services within the scope of this work. Methods of statistical analysis have been adopted together with optimization models and techniques in this research. The optimum and feasible values of the factors considered influential on objective functions have been determined as the basis of healthcare expenditure (HE) and GHCI in those relevant countries. Those released optimum outcomes are displayed between 0.64 and 0.66 in terms of desirability value. The GHCI values of those aforementioned countries range from 0 to 6. The computed average of the GHCI values of those countries is estimated as 2.4758. Finally, GHCI values of 53 countries have been calculated to set the current basis of desirability optimization models. These findings will be deemed as the basic essence of those prospective theories to be established for the future researches to constitute a new index to measure the competitiveness of healthcare systems in various countries all over the world.

The ties that bind: an integrative framework of physician-hospital alignment

Background

Alignment between physicians and hospitals is of major importance to the health care sector. Two distinct approaches to align the medical staff with the hospital have characterized previous research. The first approach, economic integration, is rooted in the economic literature, in which alignment is realized by financial means. The second approach, noneconomic integration, represents a sociological perspective emphasizing the cooperative nature of their relationship.

Discussion

Empirical studies and management theory (agency theory and social exchange theory) are used to increase holistic understanding of physician hospital alignment. On the one hand, noneconomic integration is identified as a means to realize a cooperative relationship. On the other hand, economic integration is studied as a way to align financial incentives. The framework is developed around two key antecedent factors which play an important role in aligning the medical staff. First, provider financial risk bearing is identified as a driving force towards closer integration. Second, organizational trust is believed to be important in explaining the causal relation between noneconomic and economic integration.

Summary

Hospital financial risk bearing creates a greater need for closer cooperation with the medical staff and alignment of financial incentives. Noneconomic integration lies at the very basis of alignment. It contributes directly to alignment through the norm of reciprocity and indirectly by building trust with the medical staff, laying the foundation for alignment of financial incentives.

Planning and studying improvement in patient care: the use of theoretical perspectives

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.

The impact of urban health insurance reform on hospital charges: a case study from two cities in China

During the transition from a centrally planned to a market economy, China's urban health insurance system is being reformed. The control of the rapidly increasing hospital expenses will be a major determinant of the success of the reform. This study aims to examine the impact of the reform on hospital charges by comparing changes between two cities with different insurance systems and identifying determinants for those changes. Data was collected from six hospitals in two cities, one city implemented an urban health insurance reform, the other did not. Acute appendicitis and normal childbirth were used as tracers for calculating hospital charges. Methods included the retrospective review of medical records, interviews with health policy makers and hospital staff, focus group discussions, and the review of hospital and health insurance documents. The results showed that hospital charges per case of acute appendicitis and childbirth increased 101 and 94%, respectively, in the city without reform, and 41 and 34% in the city with reform, between 1995 and 1999. Health insurance arrangements and average LOS were the major determinants for hospital charges. Drugs and non-pharmacological treatments were the major service categories for charge containment. The combined measures of a single insurer, selective contracts, a new payment system, and use of an essential drug list, is regarded as the key features for an effective hospital charge control, and would appear to be successful measures for hospital expenditure containment within health insurance reform.