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Sanderson J, Lonsdale C, Mannion R. What's Needed to Develop Strategic Purchasing in Healthcare? Policy Lessons from a Realist Review. Int J Health Policy Manag 2019; 8:4-17. [PMID: 30709098 PMCID: PMC6358649 DOI: 10.15171/ijhpm.2018.93] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 09/11/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In the context of serious concerns over the affordability of healthcare, various authors and international policy bodies advise that strategic purchasing is a key means of improving health system performance. Such advice is typically informed by theories from the economics of organization (EOO). This paper proposes that these theories are insufficient for a full understanding of strategic purchasing in healthcare, because they focus on safeguarding against poor performance and ignore the coordination and adaptation needed to improve performance. We suggest that insights from other, complementary theories are needed. METHODS A realist review method was adopted involving 3 steps: first, drawing upon complementary theories from the EOO and inter-organizational relationships (IOR) perspectives, a theoretical interpretation framework was developed to guide the review; second, a purposive search of scholarly databases to find relevant literature addressing healthcare purchasing; and third, qualitative analysis of the selected texts and thematic synthesis of the results focusing on lessons relevant to 3 key policy objectives taken from the international health policy literature. Texts were included if they provided relevant empirical data and met specified standards of rigour and robustness. RESULTS A total of 58 texts were included in the final analysis. Lessons for patient empowerment included: the need for clearly defined rights for patients and responsibilities for purchasers, and for these to be enacted through regular patientpurchaser interaction. Lessons for government stewardship included: the need for health strategy to contain specific targets to incentivise purchasers to align with national policy objectives, and for national government actors to build close, trusting relationships with purchasers to facilitate access to local knowledge about needs and priorities. Lessons for provider performance included: provider decision autonomy may drive innovation and efficient resource use, but may also create scope for opportunism, and interdependence likely to be the best power structure to incentivise collaboration needed to drive performance improvement. CONCLUSION Using complementary theories suggests a range of general policy lessons for strategic purchasing in healthcare, but further empirical work is needed to explore how far these lessons are a practically useful guide to policy in a variety of healthcare systems, country settings and purchasing process phases.
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Affiliation(s)
- Joe Sanderson
- Birmingham Business School, University of Birmingham, Birmingham, UK
| | - Chris Lonsdale
- Birmingham Business School, University of Birmingham, Birmingham, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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Islam R, Hossain S, Bashar F, Khan SM, Sikder AAS, Yusuf SS, Adams AM. Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience. Int J Equity Health 2018; 17:93. [PMID: 30286751 PMCID: PMC6172767 DOI: 10.1186/s12939-018-0805-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries. METHODS This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes. RESULTS In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts. CONCLUSIONS This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.
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Affiliation(s)
- Rubana Islam
- School of Public Health & Community Medicine, University of New South Wales (UNSW), Sydney, Australia
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shahed Hossain
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Farzana Bashar
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shaan Muberra Khan
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Adel A. S. Sikder
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sifat Shahana Yusuf
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Alayne M. Adams
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Department of International Health, Georgetown University, Washington DC, USA
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Vong S, Raven J, Newlands D. Internal contracting of health services in Cambodia: drivers for change and lessons learned after a decade of external contracting. BMC Health Serv Res 2018; 18:375. [PMID: 29788959 PMCID: PMC5964924 DOI: 10.1186/s12913-018-3165-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 04/30/2018] [Indexed: 11/18/2022] Open
Abstract
Background Since the late 1990s, contracting has been employed in Cambodia in an attempt to accelerate rural health system recovery and improve health service delivery. Special Operating Agencies (SOA), a form of ‘internal contracting’, was introduced into selected districts by the Cambodia Ministry of Health in 2009. This study investigates how the SOA model was implemented and identifies effects on service delivery, challenges in operation and lessons learned. Methods The study was carried out in four districts, using mixed methods. Key informant interviews were conducted with representatives of donors and the Ministry of Health. In-depth interviews were carried out with managers of SOA and health facilities and health workers from referral hospitals and health centres. Data from the Annual Health Statistic Report 2009–2012 on utilisation of antenatal care, delivery and immunisation were analysed. Results There are several challenges with implementation: limited capacity and funding for monitoring the SOA, questionable reliability of the monitoring data, and some facilities face challenges in achieving the targets set in their contracts. There are some positive effects on staff behaviour which include improved punctuality, being on call for 24 h service, and perceived better quality of care, promoted through adherence to work regulations stipulated in the contracts and provision of incentives. However, flexibility in enforcing these regulations in SOA has led to more dual practice, compared to previous contracting schemes. There are reported increases in utilization of services by the general population and the poor although the quantitative findings question the extent to which these increases are attributable to the contracting model. Conclusion Capacity in planning and monitoring contracts at different levels in the health system is required. Service delivery will be undermined if effective performance management is not established nor continuously applied. Improvements in the implementation of SOA include: better monitoring by the central and provincial levels; developing incentive schemes that tackle the issues of dual practice; and securing trustworthy baseline data for performance indicators.
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Affiliation(s)
- Sreytouch Vong
- Research Fellow of ReBUILD Consortium, Phnom Penh, Cambodia.
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, England
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Provider payment to primary care physicians in China: background, challenges, and a reform framework. Prim Health Care Res Dev 2018; 20:e34. [PMID: 29618391 PMCID: PMC6536753 DOI: 10.1017/s146342361800021x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To provide a framework for provider payment reform for primary care physicians in China. Background: Primary health care is central to health system reform and payment incentives have significant consequences for the equity and efficiency of it. Methods: This paper describes the special payments system for public primary health institutions and the subsequent internal salary remuneration to primary care physicians in China. Based on an analysis of the major challenges, we suggest a reform framework including the pattern of governance, and payments to primary health institutions and employed physicians. Findings: A mixed system of input-based and output-based payments to institutions would probably be appropriate under a long-term and relational contract with the government. It was also advised that internal remuneration is provided by a basic salary plus a bonus based on performance, and an extra-regional allowance. We hope that the results can be used to shift the passive budgeting of in-house staff within the public primary health institutions toward strategic purchasing.
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Abimbola S, Negin J, Martiniuk AL, Jan S. Institutional analysis of health system governance. Health Policy Plan 2017; 32:1337-1344. [DOI: 10.1093/heapol/czx083] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
| | - Joel Negin
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
| | - Alexandra L Martiniuk
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
- Dalla Lana School of Public Health, University of Toronto, ON M4N 3 M5, Canada
| | - Stephen Jan
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
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Outsourcing day surgery to private for-profit hospitals: the price effects of competitive tendering. HEALTH ECONOMICS POLICY AND LAW 2017; 13:50-67. [PMID: 28382886 DOI: 10.1017/s1744133117000019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Setting prices for elective patient treatments in private for-profit (PFP) hospitals in traditional tax-funded health systems is challenging since both the organisation of these hospitals and the tasks they perform differ considerably from what we find in public hospitals. From the year 2000, Norway became one of a few countries to gradually implement a procurement system based on competitive tendering when outsourcing elective surgery. In this study we analyse the effect of introducing competitive tendering on the prices paid to PFP hospitals. Pricing data were collected from the formal contracts awarded to PFP hospitals and defined in terms of both absolute and relative prices. We found that PFP hospitals performed day surgeries at markedly lower prices than public hospitals and that competitive tendering triggered the price reduction. We speculate that the PFP hospitals' lack of acute services, less severe patient population, reduced teaching responsibilities and ability to streamline production, as well as other factors, explain the lower prices at PFP hospitals.
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Eicher B. Selection of asset investment models by hospitals: examination of influencing factors, using Switzerland as an example. Int J Health Plann Manage 2016; 31:554-579. [PMID: 27199145 DOI: 10.1002/hpm.2341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/11/2022] Open
Abstract
Hospitals are responsible for a remarkable part of the annual increase in healthcare expenditure. This article examines one of the major cost drivers, the expenditure for investment in hospital assets. The study, conducted in Switzerland, identifies factors that influence hospitals' investment decisions. A suggestion on how to categorize asset investment models is presented based on the life cycle of an asset, and its influencing factors defined based on transaction cost economics. The influence of five factors (human asset specificity, physical asset specificity, uncertainty, bargaining power, and privacy of ownership) on the selection of an asset investment model is examined using a two-step fuzzy-set Qualitative Comparative Analysis. The research shows that outsourcing-oriented asset investment models are particularly favored in the presence of two combinations of influencing factors: First, if technological uncertainty is high and both human asset specificity and bargaining power of a hospital are low. Second, if assets are very specific, technological uncertainty is high and there is a private hospital with low bargaining power, outsourcing-oriented asset investment models are favored too. Using Qualitative Comparative Analysis, it can be demonstrated that investment decisions of hospitals do not depend on isolated influencing factors but on a combination of factors. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Bernhard Eicher
- Center of Competence for Public Management, University of Berne, Berne, Switzerland
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Abimbola S, Ukwaja KN, Onyedum CC, Negin J, Jan S, Martiniuk AL. Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria. Glob Public Health 2015; 10:1060-77. [PMID: 25652349 PMCID: PMC4696418 DOI: 10.1080/17441692.2015.1007470] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 10/17/2014] [Indexed: 11/21/2022]
Abstract
Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- National Primary Health Care Development Agency, Abuja, Nigeria
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Cajetan C. Onyedum
- College of Medicine, University of Nigeria, Enugu Campus, Nsukka, Nigeria
| | - Joel Negin
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Stephen Jan
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Alexandra L.C. Martiniuk
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Harris R, Perkins E, Holt R, Brown S, Garner J, Mosedale S, Moss P, Farrier A. Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIndependent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance.AimsTo identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice.MethodsFollowing a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners.ResultsWe found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level).ConclusionsResponses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rebecca Harris
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Elizabeth Perkins
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Robin Holt
- Department of Organisation and Management, Management School, University of Liverpool, Liverpool, UK
| | - Steve Brown
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jayne Garner
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Sarah Mosedale
- Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Phil Moss
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Alan Farrier
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
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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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Theodore BR, Whittington J, Towle C, Tauben DJ, Endicott-Popovsky B, Cahana A, Doorenbos AZ. Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation. PAIN MEDICINE 2015; 16:1045-56. [PMID: 25616057 DOI: 10.1111/pme.12688] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth. METHODS Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified. RESULTS Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth. CONCLUSIONS U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.
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Affiliation(s)
| | | | | | | | | | - Alex Cahana
- Department of Anesthesiology and Pain Medicine
| | - Ardith Z Doorenbos
- Department of Anesthesiology and Pain Medicine.,Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA, USA
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Tynkkynen LK, Keskimäki I, Lehto J. Purchaser-provider splits in health care-the case of Finland. Health Policy 2013; 111:221-5. [PMID: 23790264 DOI: 10.1016/j.healthpol.2013.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/21/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
Abstract
The purchaser-provider split (PPS) is a service delivery model in which third-party payers are kept organizationally separate from service providers. The operations of the providers are managed by contracts. One of the main aims of PPS is to create competition between providers. Competition and other incentive structures built into the contractual relationship are believed to lead to improvements in service delivery, such as improved cost containment, greater efficiency, organizational flexibility, better quality and improved responsiveness of services to patient needs. PPS was launched in Finland in the early 1990s but was not widely implemented until the early 2000s. Compared to other countries with PPS the development and implementation of PPS in Finland has been unusual. Firstly, purchasing is implemented at the level of municipalities, which means that the size of the Finnish purchasers is extremely small. Elsewhere purchasing is mostly implemented at the regional or national levels. Secondly, PPS is also applied to primary health care and A&E services while in other countries the services mainly include specialized health care and residential care for the elderly. Thirdly, PPS in health and social services is not regulated by any specific legislation, regulative mechanisms or guidelines. Instead it is regulated within the same framework as public procurement in general.
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Affiliation(s)
- Liina-Kaisa Tynkkynen
- University of Tampere, School of Health Sciences, School of Health Sciences FI-33014 University of Tampere, Finland.
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Abstract
BACKGROUND Over the past three decades, a limited range of market like mechanisms have been introduced into the hierarchically structured English National Health Service ('NHS'), which is a nationally tax funded, budget limited healthcare system, with access to care for all, producing structures known as a quasi market. Recently, the Health and Social Care Act 2012 ('HSCA') has been enacted, introducing further market elements. The paper examines the theory and effects of these market mechanisms. METHODS Using neo-classical economics as a primary theoretical framework, as well as new institutional economics and socio-legal theory, the paper first examines the fundamental elements of markets, comparing these with the operation of authority and resource allocation employed in hierarchical structures. Second, the paper examines the application of market concepts to the delivery of healthcare, drawing out the problems which economic and socio-legal theories predict are likely to be encountered. Third, the paper discusses the research evidence concerning the operation of the quasi market in the English NHS. This evidence is provided by research conducted in the UK which uses economic and socio-legal logic to investigate the operation of the economic aspects of the NHS quasi market. Fourth, the paper provides an analysis of the salient elements of the quasi market regime amended by the HSCA 2012. RESULTS It is not possible to construct a market conforming to classical economic principles in respect of healthcare. Moreover, it is not desirable to do so, as goals which markets cannot deliver (such as fairness of access) are crucial in England. Most of the evidence shows that the quasi market mechanisms used in the English NHS do not appear to be effective either. This finding should be seen in the light of the fact that the operation of these mechanisms has been significantly affected by the national political (i.e. continuingly hierarchical) and budgetary context in which they are operating. CONCLUSION The organisational structures of a hierarchy are more appropriate for the delivery of healthcare in the English NHS.
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Affiliation(s)
- Pauline Allen
- London School of Hygiene and Tropical Medicine, London, UK.
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14
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Loureiro S, Ferreira Júnior HDM, Mota FB, Freitas LFDS. Uma análise exploratória dos programas de controle da tuberculose da bahia e goiás à luz da teoria dos custos de transação. SAUDE E SOCIEDADE 2013. [DOI: 10.1590/s0104-12902013000100009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Em caráter exploratório, o objetivo deste artigo é analisar o Programa de Controle da Tuberculose (PCTs) dos Estados da Bahia e Goiás e respectivas capitais, Salvador e Goiânia, a partir da Teoria dos Custos de Transação. Para tanto, foi realizado um estudo de caso nos PCTs citados, utilizando-se, junto aos seus gestores, do método de entrevistas aprofundadas semidiretivas. Os resultados sugerem: (a) baixa especificidade em ativos humanos; (b) baixo grau de incerteza - relacionada à flutuação da demanda e à introdução de novas tecnologias (medicamentos); (c) aspectos relacionados à racionalidade limitada (informação incompleta) são pouco relevantes - no que tange à redação do contrato (Programa Nacional de Controle da Tuberculose - PNCT) e ao Sistema de Informação de Agravos de Notificação (SINAN); (d) e alta probabilidade de ocorrência de comportamento de tipo oportunista (risco moral) - devido ao não monitoramento das ações, à ausência de punições em caso de descumprimento das ações pactuadas no PNCT e ao regime de incentivos vigente.
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15
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Allen P, Turner S, Bartlett W, Perotin V, Matchaya G, Zamora B. Provider Diversity in the English NHS: A Study of Recent Developments in Four Local Health Economies. J Health Serv Res Policy 2012; 17 Suppl 1:23-30. [DOI: 10.1258/jhsrp.2011.011015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objectives To assess the impact of provider diversity on quality and innovation in the English NHS by mapping the extent of diverse provider activity and identifying the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organizations within the NHS, and the factors that affect the entry and growth of new providers. Methods Case studies of four local health economies. Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and third sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results Involvement of diverse providers in the NHS is limited. Commissioners' local strategies influence degrees of diversity. Barriers to entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions There is scope to increase the participation of diverse providers in the NHS but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.
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Affiliation(s)
| | - Simon Turner
- NIHR King's Patient Safety and Service Quality Research Centre, King's College London
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16
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The use of standard contracts in the English National Health Service: a case study analysis. Soc Sci Med 2011; 73:185-92. [PMID: 21684643 DOI: 10.1016/j.socscimed.2011.05.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 04/21/2011] [Accepted: 05/03/2011] [Indexed: 11/21/2022]
Abstract
The use of contracts is vital to market transactions. The introduction of market reforms in health care in the U.K. and other developed countries twenty years ago meant greater use of contracts. In the U.K., health care contracting was widely researched in the 1990s. Yet, despite the changing policy context, the subject has attracted less interest in recent years. This paper seeks to fill a gap by reporting findings from a study of contracting in the English National Health Service (NHS) after the introduction of the national standard contract in 2007. By using economic and socio-legal theories and two case studies we examine the way in which the new contract was implemented in practice and the extent to which implementation conformed to policy intentions and to our theoretical predictions. Data were collected using non-participant observation of 36 contracting meetings, 24 semi-structured interviews, and analysis of documents. We found that despite efforts to introduce a more detailed ('complete') contract, in practice, purchasers and providers often reverted to a more relational style of contracting. Frequently reliance on the NHS hierarchy proved to be indispensable; in particular, formal dispute resolution was avoided and financial risk was re-allocated in compromises that sometimes ignored contractual provisions. Serious data deficiencies and shortages of skilled personnel still caused major difficulties. We conclude that contracting for health care continues to raise serious problems, which may be exacerbated by the impending transfer of responsibility to groups of general practitioners (GPs) who generally lack experience and expertise in large-scale, secondary care contracting.
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17
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What can transaction costs tell us about governance in the delivery of large scale HIV prevention programmes in southern India? Soc Sci Med 2011; 72:1939-47. [PMID: 21349622 PMCID: PMC3125695 DOI: 10.1016/j.socscimed.2011.01.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/10/2011] [Accepted: 01/26/2011] [Indexed: 10/31/2022]
Abstract
This paper aims to understand the transaction costs implications of two different governance modes for large scale contracting of HIV prevention services to non-governmental organisations (NGOs) in 2 states in India as part of the National AIDS Control Programme between 2001 and 2003. Interviews at purposively selected case study NGOs, contracting agencies and key informants as well as document review were used to compile qualitative data and make comparisons between the states on five themes theoretically proposed to shape transaction costs: institutional environment, informational problems, opportunism, scale of activity and asset specificity (the degree to which investments made specifically for the contract have value elsewhere). The State AIDS Control Society (SACS) in state Y used a management agency to manage the NGO contracts whereas the SACS in state X contracted directly with the NGOs. A high level of uncertainty, endemic corruption and weak information systems served to weaken the contractual relationships in both states. The management agency in state Y enabled the development of a strong NGO network, greater transparency and control over corrupt practises than the contract model in state X. State X's contractual process was further weakened by inadequate human resources. The application of the transaction cost framework to contracting out public services to NGOs identified the key costs associated with the governance of HIV prevention services through NGO contracts in India. A more successful form of relational contract evolved within the network of the contract management agency and the NGOs. This led to improved flows of information and perceived quality, and limited corrupt practises. It is unlikely that the SACS on its own, with broader responsibilities and limited autonomy can achieve the same ends. The management agency approach therefore appears to be both transaction cost reducing and better able to cope with the large scale of these contracting programmes.
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18
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Donato R. Extending transaction cost economics: towards a synthesised approach for analysing contracting in health care markets with experience from the Australian private sector. Soc Sci Med 2010; 71:1989-96. [PMID: 20943302 DOI: 10.1016/j.socscimed.2010.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 08/04/2010] [Accepted: 09/08/2010] [Indexed: 10/19/2022]
Abstract
Transaction cost economics (TCE) has been the dominant economic paradigm for analysing contracting, and the framework has been applied in a number of health care contexts. However, TCE has particular limitations when applied to complex industry settings and there have been calls to extend the framework to incorporate dynamic theories of industrial organisation, specifically the resource-based view (RBV). This paper analyses how such calls for theoretical pluralism are particularly germane to health care markets and examines whether a combined TCE-RBV provides a more comprehensive approach for understanding the nature of contractual arrangements that have developed within the Australian private health care sector and its implications for informing policy. This Australian case study involved a series of interviews with 14 senior contracting executives from the seven major health funds (i.e. 97% of the insured population) and seven major private hospital groups (i.e. 73% of the private hospital beds). Study findings reveal that both the TCE perspective with its focus on exchange hazards, and the RBV approach with its emphasis on the dynamic nature of capabilities, each provide a partial explanation of the developments associated with contracting between health funds and hospital groups. For a select few organisations, close inter-firm relational ties involving trust and mutual commitment attenuate complex exchange hazards through greater information sharing and reduced propensity to behave opportunistically. Further, such close relational ties also provide denser communication channels for creating and transmitting more complex information enabling organisations to tap into each other's complementary resources and capabilities. For policymakers, having regard to both TCE and RBV considerations provides the opportunity to apply competition policy beyond the current static notions of efficiency and welfare gains, and cautions policymakers against specifying ex ante the specific nature of contractual arrangements that ought to prevail in health care markets.
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Affiliation(s)
- Ronald Donato
- School of Commerce, University of South Australia, City West Campus, North Terrace, Adelaide, South Australia, Australia.
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19
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Lavoie J, Boulton A, Dwyer J. Analysing contractual environments: lessons from Indigenous health in Canada, Australia and New Zealand. PUBLIC ADMINISTRATION 2010; 88:665-679. [PMID: 20919430 DOI: 10.1111/j.1467-9299.2009.01784.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Contracting in health care is a mechanism used by the governments of Canada, Australia and New Zealand to improve the participation of marginalized populations in primary health care and improve responsiveness to local needs. As a result, complex contractual environments have emerged. The literature on contracting in health has tended to focus on the pros and cons of classical versus relational contracts from the funder's perspective. This article proposes an analytical framework to explore the strengths and weaknesses of contractual environments that depend on a number of classical contracts, a single relational contract or a mix of the two. Examples from indigenous contracting environments are used to inform the elaboration of the framework. Results show that contractual environments that rely on a multiplicity of specific contracts are administratively onerous, while constraining opportunities for local responsiveness. Contractual environments dominated by a single relational contract produce a more flexible and administratively streamlined system.
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Affiliation(s)
- Josée Lavoie
- UNBC-Health Sciences, Prince George, British Columbia
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20
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Abstract
It is argued here that an economics centred on subjective utility-maximization is unsuitable for the analysis and policy grounding of health care provision. To some extent, the peculiarities of health care have been recognized by mainstream health economists, who sometimes abandon Paretian welfare considerations to focus on needs instead. This article examines important peculiarities of health care that are relatively neglected in the literature. Some of these concern health care needs: while health itself is a universal need, needs for health care provision are largely involuntary, varied, and idiosyncratic. These issues have important consequences for the planning of health care systems and the extent of transaction costs in any market-based system. These factors, combined with the inherent dynamism of modern health care needs and capabilities, create an opening for alternative approaches to health care economics.
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21
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Abstract
Outsourcing and privatization of healthcare services are analyzed from management and economics perspectives, examining four types of outsourcing from the transaction costs theory: centres, clinical services, diagnostic-therapeutic support services, and ancillary services. Potential effects of outsourcing are analysed, addressing the advantages and risks, and putting it into the context of the Spanish NHS. Some final remarks are made regarding policy and research agenda.
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22
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Jan S, Pronyk P, Kim J. Accounting for institutional change in health economic evaluation: a program to tackle HIV/AIDS and gender violence in Southern Africa. Soc Sci Med 2007; 66:922-32. [PMID: 18162273 DOI: 10.1016/j.socscimed.2007.11.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Indexed: 11/17/2022]
Abstract
There has been growing interest in the application of institutionalist perspectives in the health economics literature. This paper investigates the institutionalist notion of social value and its use in economic evaluation with particular reference to a program to address HIV/AIDS and gender violence in Southern Africa (IMAGE). Institutions are the rules that govern the conduct between individuals, groups and organisations. Their social value stems from their capacity to reduce the uncertainty in human interactions thereby both reducing transaction costs and, importantly, enabling the initiation and sustainability of various activities (instrumental value). Furthermore, institutions tend to be formed around certain ethical positions and as a consequence, act in binding future decision making to these positions (intrinsic value). Incorporating such notions of social value within a conventional welfare-based measure of benefit is problematic as institutional development is not necessarily consistent with individual utility. An institutionalist approach allows for these additional domains to be factored into economic evaluation. IMAGE is an intervention to reduce gender violence and HIV through microfinance, health education and community development, and involves significant initial investment in institution-building activities, notably through training activities with program staff and community members. The key to employing an institutionalist approach to the evaluation of IMAGE is in understanding the nature of those actions that can be seen as institution-building and determining: (1) the instrumental value of follow-up activities by appropriate amortisation of transaction costs over an horizon that reflects the economies gained from the intervention; and (2) the intrinsic value of any transformation in the community through a cost-consequences approach informed by an a priori conceptual model. This case study highlights how health sector interventions can effect institutional changes and how these are captured within a theory-based economic evaluation framework.
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Affiliation(s)
- Stephen Jan
- The George Institute for International Health, P.O. Box M201, Missenden Road, Camperdown, NSW 2050, Australia.
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23
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Marini G, Street A. A transaction costs analysis of changing contractual relations in the English NHS. Health Policy 2006; 83:17-26. [PMID: 17166619 DOI: 10.1016/j.healthpol.2006.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 11/10/2006] [Accepted: 11/14/2006] [Indexed: 10/23/2022]
Abstract
The English National Health Service has replaced locally negotiated block contracting arrangements with a system of national prices to pay for hospital activity. This paper applies a transaction costs approach to quantify and analyse the nature of how contracting costs have changed as a consequence. Data collection was based on semi-structured interviews with key stakeholders from hospitals and Primary Care Trusts, which purchase hospital services. Replacing block contracting with activity based funding has led to lower costs of price negotiation, but these are outweighed by higher costs associated with volume control, of data collection, contract monitoring, and contract enforcement. There was consensus that the new contractual arrangements were preferable, but the benefits will have to be demonstrated formally in future.
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Affiliation(s)
- Giorgia Marini
- Centre for Health Economics, University of York, York YO10 5DD, UK
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24
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Ashton T, Cumming J, McLean J. Contracting for health services in a public health system: the New Zealand experience. Health Policy 2005; 69:21-31. [PMID: 15484604 DOI: 10.1016/j.healthpol.2003.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This paper reports on the process and outcomes of contracting for health services in New Zealand between 1993 and 2000 when a purchaser-provider split was in place. Key factors that shaped the contracting environment were the legal framework, funding constraints, and the cultural and professional norms of contracting personnel. A lack of good information-especially on costs, volumes and quality-increased the costs of contracting and made monitoring and accountability difficult. Over time, however, the contracting process became simpler and less costly. Overall, the introduction of contracting generally improved the focus of providers on costs and volumes; led to greater clarity through specification of services; encouraged providers to focus on methods to improve quality; and enabled new styles of service provision from providers that had not traditionally received public funds for health services. Good relationships between purchasers and providers were seen as the key to successful contracting.
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Affiliation(s)
- Toni Ashton
- Centre for Health Services Research and Policy, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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25
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Crampton P, Starfield B. A case for government ownership of primary care services in New Zealand: weighing the arguments. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2005; 34:709-27. [PMID: 15560431 DOI: 10.2190/fmjw-r4r9-c4r1-w8rj] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Primary care services provide continuing and coordinating care, cater to most health care needs, and serve as a point of first contact with the health system. This article addresses the issue of government ownership of primary care. Ownership confers governance responsibility (ultimate control) for an organization, and accountability for its actions. Primary care organizations can be classed as government owned and operated or privately owned and operated, the latter with or without community governance. The authors address two policy questions: Does the ownership form of a primary care organization matter? What ownership frameworks should be used to guide policymaking? Arguments for and against government ownership are examined from political and economic perspectives, informed by a governance framework. Government ownership of primary care may solve problems associated with private for-profit ownership that are related to lack of control of strategic assets, lack of direct political accountability, contracting, and market failure, but it may raise potential problems of lack of responsiveness to minority and local needs and capture by interest groups. In response to the problems associated with government ownership, community-governed private nonprofits have an essential role as a vehicle for indigenous self-determination, catering for minority populations, experimenting with policy options, and providing public goods particularly for minority populations. The authors argue that private organizations that lack community governance have a lesser role.
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26
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Simonet D. Where does the US experience of managed care currently stand? Int J Health Plann Manage 2005; 20:137-57. [PMID: 15991459 DOI: 10.1002/hpm.803] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
After an historical review of the advent of managed care in the USA, this article presents cost-control mechanisms, changes in the medical practice and consequences on patient health. The article also explains the development of the HMO using the transaction costs theory and the subsequent orientations of the US health care system.
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Affiliation(s)
- D Simonet
- Nanyang Business School, Nanyang Technological University, Singapore.
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27
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Abelson J, Gold ST, Woodward C, O'Connor D, Hutchison B. Managing under managed community care: the experiences of clients, providers and managers in Ontario's competitive home care sector. Health Policy 2004; 68:359-72. [PMID: 15113647 DOI: 10.1016/j.healthpol.2003.10.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2003] [Revised: 10/23/2003] [Accepted: 10/30/2003] [Indexed: 10/26/2022]
Abstract
In 1996, a newly elected government in the Province of Ontario, Canada, introduced a managed competition environment into the home care sector through the establishment of a competitive contracting process for home care services. Through 65 in-depth, semi-structured interviews conducted between November 1999 and January 2001, we trace the implementation of this competitive contracting policy within Ontario's newly established managed community care environment and assess the effects of competitive contracting against two sets of goals: (1). quality of care goals that consider continuity of care of paramount importance in the provision of home care; and (2). the managed competition goal of increased efficiency. In assessing the implementation of this policy against these goals, we highlight the conflicts that can arise in pursuing different policy goals in response to different formulations of the policy problem that underpin them. We map stakeholder experiences with the competitive contracting policy onto relevant contracting and managed competition literatures. When measured against the goals of quality of care and efficiency, the findings presented here offer a mixed review of the experiences to date with the competitive contracting process introduced in Ontario's home care sector and suggest improvements for managing future competitive contracting processes.
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Affiliation(s)
- Julia Abelson
- Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, Health Sciences Centre, McMaster University, Rm 3H28, 1200 Main Street West, Hamilton, Ont, Canada L8N 3Z5.
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Bahli B, Rivard S. The Information Technology Outsourcing Risk: A Transaction Cost and Agency Theory-Based Perspective. JOURNAL OF INFORMATION TECHNOLOGY 2003. [DOI: 10.1080/0268396032000130214] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Many firms have adopted outsourcing in recent years as a means of governing their information technology (IT) operations. While outsourcing is associated with significant benefits, it can also be a risky endeavour. This paper proposes a scenario-based conceptualization of the IT outsourcing risk, wherein risk is defined as a quadruplet comprising a scenario, the likelihood of that scenario, its consequences and the risk mitigation mechanisms that can attenuate or help avoid the occurrence of a scenario. This definition draws on and extends a risk assessment framework that is widely used in engineering. The proposed conceptualization of risk is then applied to the specific context of IT outsourcing using previous research on IT outsourcing as well as transaction cost and agency theory as a point of departure.
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Affiliation(s)
- Bouchaib Bahli
- Decision Sciences and Management Information Systems, The John Molson School of Business, Concordia University, Montreal, Canada H3G 1M8
| | - Suzanne Rivard
- HEC Montreal, 3000 Chemin de la Cote-Ste-Catherine, Montreal, Canada H3T 2A7
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29
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Lien L. Financial and organisational reforms in the health sector; implications for the financing and management of mental health care services. Health Policy 2003; 63:73-80. [PMID: 12468119 DOI: 10.1016/s0168-8510(02)00054-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Since 1980 many developed countries have planned and implemented health sector reforms of different scales and ambitions. Norway has been no exception, and the main political aspirations have been to increase efficiency and improve consumer choice and responsiveness. The major financial reform was the introduction of an activity based financing based on diagnostic related groups (DRG). Other central reforms include legislative rights for patients to choose hospital of their own choice, and the handing over of the responsibility of hospital based care form the county to the state. For some of these reforms mental health care is not included. The aim of the study is to appraise with examples from different countries whether it is feasible include metal health care into the reforms and whether the reforms in general are conducive for mental health care policy goals. The problems are elaborated and discussed at the level of technically and politically feasibility and the costs involved.
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Affiliation(s)
- Lars Lien
- NORAD, Ruseløkkveien 26, P.b. 8034, dep, N-0030 Oslo, Norway.
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30
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Cumming J, Mays N. Reform and counter reform: how sustainable is New Zealand's latest health system restructuring? J Health Serv Res Policy 2002; 7 Suppl 1:S46-55. [PMID: 12175435 DOI: 10.1258/135581902320176476] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
New Zealand's health care sector has undergone almost continual restructuring since the early 1980s. In the latest set of reforms, 21 district health boards (DHBs) have been established with responsibility for promoting health, purchasing services for their populations and delivering publicly owned health services. Boards will be governed by a mix of elected and appointed members, will be responsible for arranging the delivery of primary and community health services, and will own and run public hospitals and related facilities. We clarify the differences and continuities between earlier reforms and the 2000/01 structures, as well as the current reforms' potential strengths and weaknesses. The paper discusses whether the DHB model was the only feasible option for restructuring and whether the dynamics of the new system may lead to further changes, particularly on the purchaser side of the system. Given that DHBs face potential conflict between their purchasing and provision roles, and given the potential advantages that primary care organisations may have as purchasers, we conclude that it is possible that all or part of the purchasing function of DHBs might eventually shift to primary care organisations, leaving the DHBs as hospital-based provider organisations.
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Affiliation(s)
- Jackie Cumming
- Health Services Research Centre, Institute of Policy Studies, Victoria University of Wellington, New Zealand
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31
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Abstract
Women are a heterogeneous group with varying experiences and needs of health care systems. It is important that we recognise not only differences between women, but also that individual women may have different, even contradictory, health care issues and needs. These may vary according to women's different roles, identities, contexts, and resources (financial, social, etc.). This paper explores situated ideas about identity, gender, and place and how these relate to perceptions of accessibility of health care services in the context of New Zealand's restructured health care system.
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Affiliation(s)
- Janine Wiles
- Department of Geography, Queen's University, Kingston, Ont., Canada K7L 3N6.
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32
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Allen P. A socio-legal and economic analysis of contracting in the NHS internal market using a case study of contracting for district nursing. Soc Sci Med 2002; 54:255-66. [PMID: 11824930 DOI: 10.1016/s0277-9536(01)00025-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The introduction of an internal market in the National Health Service (NHS) in the United Kingdom necessitated the use of contracts between purchasers and providers. Little thought was given to the nature of these contracts by policy makers, who appeared to assume that the contracts could conform to the classical, complete model. This paper uses socio-legal and economic theories of contract (which provide an alternative model of relational contracts, in contrast to classical contracts) to explore how realistic that assumption was. An analysis of the institutional context in which the contracts were made is provided, including a legal analysis of the relevant legislation. Contracting by health authorities and GP fundholders is examined, using the results of a recent case study of contracting for district nursing services carried out in a health authority in Greater London. The results show that classical contracting is an inappropriate model for NHS contracts, but that relational contracting is not an entirely appropriate model either. Contracting was found to have increased the accountability of providers in respect of some financial matters, but not in respect of the quality of district nursing services. There are negative implications for the use of contracting in publicly financed health services--hierarchies may be more efficient (as lower transaction costs can be incurred) and possibly more effective in improving quality of care.
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Affiliation(s)
- Pauline Allen
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, UK. pauline.allen@
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33
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Dew K, Roorda M. Institutional innovation and the handling of health complaints in New Zealand: an assessment. Health Policy 2001; 57:27-44. [PMID: 11348692 DOI: 10.1016/s0168-8510(01)00132-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This paper explores innovations in health complaints mechanisms in New Zealand, focusing on two legislative developments-The Health and Disability Commissioner Act 1994 and the Medical Practitioners Act 1995. Both pieces of legislation were introduced during a time of far-reaching institutional change in New Zealand, and were influenced by the findings of unethical practices by medical researchers at a women's hospital in Auckland. Although the legislation was driven by concerns over consumer rights and in particular women's health, there have been some unanticipated developments. An assessment is made of the impact of these innovations, based on the analysis of a number of data sources, including media reports, complaint reports and submissions to select committee hearings. The regulatory environment in New Zealand left health consumers heavily dependent on the medical profession's internal mechanisms of regulation. The failure of this internal regulation led to new external regulatory mechanisms designed to empower the consumer. The analysis suggests that even when empowerment appears to be written into legislation there are mechanisms available to limit empowerment further.
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Affiliation(s)
- K Dew
- Department of Public Health, Wellington School of Medicine, University of Otago, P.O. Box 7343, Wellington, New Zealand.
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Abstract
The 1993 Health and Disability Services Act heralded a range of structural reforms in the New Zealand health care system. Despite these reforms considerable resources being spent on convincing consumers of their merits, have failed to gain widespread public approval. This paper examines two key issues that have arisen during the reform process. These are the difficulties associated with trying to set priorities in ways which are effective and politically acceptable, and the relationship between the public and private sectors. Unacknowledged conflicts of interest have helped to undermine the priority setting process. The discussion suggests that it may be increasingly difficult for any government in future to determine the allocation of resources without taking private sector interests and rising public concern into account. It remains to be seen which of these factors is more powerful.
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Affiliation(s)
- P Howden-Chapman
- Department of Public Health, Wellington School of Medicine, University of Otago, P.O. Box 7343, South, Wellington, New Zealand.
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Light DW. Sociological perspectives on competition in health care. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2000; 25:969-974. [PMID: 11068742 DOI: 10.1215/03616878-25-5-969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- D W Light
- University of Medicine and Dentistry of New Jersey, USA
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Kearns RA, Joseph AE. Contracting opportunities: interpreting post-asylum geographies of mental health care in Auckland, New Zealand. Health Place 2000; 6:159-69. [PMID: 10936772 DOI: 10.1016/s1353-8292(00)00020-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In New Zealand, the process of deinstitutionalization is continuing to unfold as a specific manifestation of welfare state restructuring rather than as a discrete process within the health care sector. In this paper we consider the geography of mental health care in Auckland, New Zealand's only metropolitan city. Here, a highly fluid and competitive housing market has profoundly (re)shaped the opportunities for community care. We report on findings from a survey of representatives of the key agencies providing mental health care in central Auckland. We argue that the re-placing of mental health care into the community has often involved the separation of residential and treatment issues, to the detriment of the communities, institutions and (especially) individuals involved. We trace this fragmentation back to the primacy of the ideology of restructuring over the philosophy of deinstitutionalization. We build our argument around a discussion of the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the apparent subordination of the Act to the emerging of a 'contract state' and broader legislation, such as the Resource Management Act 1991, the Privacy Act 1992 and the Commerce Act 1986, which underpins the re-regulation of New Zealand society.
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Affiliation(s)
- R A Kearns
- Department of Geography, The University of Auckland, Private Bag 92019, Auckland, New Zealand
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Abstract
OBJECTIVES To examine whether longer-term contracts for health services will shift attention away from concern for finance and activity levels and towards the achievement of better quality services. METHODS Analysis of 288 contracts from the British National Health Service (NHS) and 12 semi-structured interviews with staff from provider (NHS hospital trusts) and purchaser (health authorities) organisations. RESULTS No relationship was found between the duration of a contract and the duration of service specifications or quality frameworks. The annual contracting cycle is concerned largely with ensuring that all parties stay within activity targets and financial constraints, and this is unlikely to be affected by a shift to longer-term contracts. The setting of standards and initiatives to improve quality is largely independent of the contracting process and the duration of contracts, and relies on relationships rather than contracts. CONCLUSIONS It is optimistic to expect longer-term contracts automatically to produce a greater focus on quality and the incentives needed to ensure that improvements in quality are delivered. However, this may not matter as issues of quality are being addressed more appropriately in the British NHS through a variety of other routes.
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Affiliation(s)
- M Goddard
- Centre for Health Economics, University of York, UK
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