Competition, payers, and hospital quality

Waiting times spillovers in a National Health Service hospital network: a little organizational diversity can go a long way

BACKGROUND

The objective of this study is to assess if waiting times for elective surgeries within the Portuguese National Health Service (NHS) are influenced by the waiting times at neighboring hospitals. Recognizing these interdependencies, and their extent, is crucial for understanding how hospital network dynamics affect healthcare delivery efficiency and patient access.

METHODS

We utilized patient-level data from all elective surgeries conducted in Portuguese NHS hospitals to estimate a hospital-specific index for waiting times. This index served as the dependent variable in our analysis. We applied a spatial lag model to examine the potential strategic interactions between hospitals concerning their waiting times.

RESULTS

Our analysis revealed a significant positive endogenous spatial dependence, indicating that waiting times in NHS hospitals are strategic complements. Furthermore, we found that NHS contracts with private not-for-profit hospitals not only reduce waiting times within these hospitals but also exert positive spillover effects on other NHS hospitals.

CONCLUSIONS

The findings suggest that diversifying the organization of the NHS hospital network, particularly through contracts with private entities for marginal patients, can significantly enhance competitive dynamics and reduce waiting times. This effect persists even when patient choice is confined to a small fraction of the patient population, highlighting a strategic avenue for policy optimization in healthcare service delivery.

Measuring competition in primary care-Evidence from Sweden

INTRODUCTION

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

AIM

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

METHODS

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape-our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

RESULTS

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

CONCLUSIONS

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Hospital competition and health outcomes: Evidence from acute myocardial infarction admissions in Germany

Countries increasingly rely on competition among hospitals to improve health outcomes. However, there is limited empirical evidence on the effect of competition on health outcomes in Germany. We examined the effect of hospital competition on quality of care, which is assessed using health outcomes (risk-adjusted in-hospital and post-hospitalization mortality and cardiac-related readmissions), focusing on acute myocardial infarction (AMI) treatment. We obtained data on all hospital utilizations and mortality of 13.2% of the population from a large statutory health insurer and all AMI admission records from Diagnosis-Related Groups Statistic from 2015-19. We constructed the measures of hospital competition, which mitigates the possibility of endogeneity bias. The relationships between health outcomes and competition measures are estimated using linear probability models. Intense competition was associated with lower quality of care in terms of mortality and cardiac-related readmissions. Patients treated in hospitals facing high competition were 0.9 (1.2) percentage points more likely to die within 90 days (2 years) of admission, and 1.4 (1.6) percentage points more likely to be readmitted within 90 days (2 years) of discharge than patients treated in hospitals facing low competition. Our results indicate that hospital competition does not lead to better health outcomes for AMI patients in Germany. Therefore, additional measures are necessary to achieve quality improvement.

Heterogeneous effects of hospital competition on inpatient quality: an analysis of five common diseases in China

BACKGROUND

Many countries has introduced pro-competition policies in the delivery of healthcare to improve medical quality, including China. With the increasing intensity of competition in China's healthcare market, there are rising concerns among policymakers about the impact of hospital competition on quality. This study investigated heterogeneous effects of hospital competition on inpatient quality.

METHODS

We analyzed the inpatient discharge dataset and selected chronic obstructive pulmonary disease (COPD), ischemic stroke, pneumonia, hemorrhagic stroke, and acute myocardial infarction (AMI) as representative diseases. A total of 561,429 patients in Sichuan Province in 2017 and 2019 were included. The outcomes of interest were in-hospital mortality and 30-day unplanned readmissions. The Herfindahl-Hirschman Index was calculated using predicted patient flows to measure hospital competition. To address the spatial correlations of hospitals and the structure of the dataset, the multiple membership multiple classification model was employed for analysis.

RESULTS

Amid intensifying competition in the hospital market, our study discerned no marked statistical variance in the risk of inpatient quality across most diseases examined. Amplified competition exhibited a positive correlation with heightened in-hospital mortality for both COPD and pneumonia patients. Elevated competition escalated the risk of 30-day unplanned readmissions for COPD patients, while inversely affecting the risk for AMI patients.

CONCLUSIONS

There is the heterogeneous impact of hospital competition on quality across various diseases in China. Policymakers who intend to leverage hospital competition as a tool to enhance healthcare quality must be cognizant of the possible influences of it.

Public and Private Options in Practice: The Military Health System

Recent debates over health care reform, including in the context of the Military Health System (MHS) and Veterans Administration, highlight the dispute between public and private provision of health care services. Using novel data on childbirth claims from the MHS and drawing on the combination of plausibly exogenous patient moves and heterogeneity across bases in the availability of base hospitals, we identify the impact of receiving obstetrical care on versus off military bases. We find evidence that off-base care is associated with slightly greater resource intensity, but also notably better outcomes, suggesting marginal efficiency gains from care privatization.

COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition

The United States has one of the highest cumulative mortalities of coronavirus disease 2019 (COVID-19) and has reached 1 million deaths as of May 19th, 2022. Understanding which community and hospital factors contributed to disparities in COVID-19 mortality is important to inform public health strategies. This study aimed to explore the potential relationship between hospital service area (1) community (ie, health professional shortage areas, market competition, and uninsured percentage) and (2) hospital (ie, teaching, system, and ownership status) characteristics (2013-2018) on publicly available COVD-19 (February to October 2020) mortality data. The study included 2514 health service areas and used multilevel mixed-effects linear model to account for the multilevel data structure. The outcome measure was the number of COVID-19 deaths. This study found that public health, as opposed to acute care provision, was associated with community health and, ultimately, COVID-19 mortality. The study found that population characteristics including more uninsured greater proportion of those over 65 years, more diverse populations, and larger populations were all associated with a higher rate of death. In addition, communities with fewer hospitals were associated with a lower rate of death. When considering region in the United States, the west region showed a higher rate of death than all other regions. The association between some community characteristics and higher COVID-19 deaths demonstrated that access to health care, either for COVID-19 infection or worse health from higher disease burden, is strongly associated with COVID-19 deaths. Thus, to be better prepared for potential future pandemics, a greater emphasis on public health infrastructure is needed.

Inter-Regional Patients' Migration for Hospital Orthopedic Intensive Rehabilitation: The Italian Experience

BACKGROUND

Following the introduction of administrative federalism in the Italian National Health Service, inter-regional patients' mobility has become increasingly relevant because, in addition to being an indirect index of the quality of care, it has important economic and financial implications. This study aimed to evaluate the fulfillment of the need for hospital orthopedic intensive rehabilitation on site and care-seeking patients' migration to other regions.

METHODS

From 2011 to 2019, the data of intensive orthopedic rehabilitation extracts from the Hospital Discharge Cards provided by Italian Ministry of Health were analyzed. We studied the hospital networks of every Italian region (catchment areas). The epidemiological flows of inter-regional mobility were analyzed with Gandy's Nomogram, while the financial flows were analyzed through Attraction Absorption and Escape Production Indexes.

RESULTS

Gandy's Nomogram showed that only Piedmont, Lombardy, A.P. of Trento, E. Romagna, Umbria and Abruzzo had good public hospital planning for intensive orthopedic rehabilitation, with a positive balance for all studied periods. Lombardy, E. Romagna, Piedmont, Veneto and Latium have absorbed approximately 70% of all financial flows (about EUR 60.5 million).

CONCLUSIONS

Only six regions appear to be able to satisfy the care needs of their residents, with a positive epidemiological and financial balance for all studied periods.

Ways to Improve Hospital Quality - A Health System Perspective Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies"

Wackers and colleagues' scoping review provides an informative and well-structured overview of hospital-based case studies focusing on integrated hospital strategies that seek to improve quality, while reducing or containing costs. Wackers et al take a hospital level perspective and evaluate facilitators and barriers to the successful implementation of those hospital strategies. I complement the hospital level perspective of Wackers et al with an analysis from a health system perspective. Regulations at the superordinate system level might influence decisions at the hospital level that are relevant for costs and quality of care. In this commentary, I discuss how interventions at the system level might affect hospital quality. The results suggest that especially competition between hospitals, pay for performance (PfP) initiatives in combination with publication of quality information, but also greater experience of hospital staff (as proxied by the volume outcome relationship) may provide impulses for improving quality of care.

Can competition improve hospital quality of care? A difference-in-differences approach to evaluate the effect of increasing quality transparency on hospital quality

Public reporting on the quality of care is intended to guide patients to the provider with the highest quality and to stimulate a fair competition on quality. We apply a difference-in-differences design to test whether hospital quality has improved more in markets that are more competitive after the first public release of performance data in Germany in 2008. Panel data from 947 hospitals from 2006 to 2010 are used. Due to the high complexity of the treatment of stroke patients, we approximate general hospital quality by the 30-day risk-adjusted mortality rate for stroke treatment. Market structure is measured (comparatively) by the Herfindahl-Hirschman index (HHI) and by the number of hospitals in the relevant market. Predicted market shares based on exogenous variables only are used to compute the HHI to allow a causal interpretation of the reform effect. A homogenous positive effect of competition on quality of care is found. This effect is mainly driven by the response of non-profit hospitals that have a narrow range of services and private for-profit hospitals with a medium range of services. The results highlight the relevance of outcome transparency to enhance hospital quality competition.

The Different Classification of Hospitals Impact on Medical Outcomes of Patients in China

Background

In China, different classification of hospitals (COH) provide treatment for patients with different degrees of illness. COH play an important role in Chinese medical outcomes, but there is a lack of quantitative description of how much impact the results have. The objective of this study is to examine the correlation between COH on medical outcomes with the hope of providing insights into appropriate care and resource allocation.

Methods

From the perspective of the COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with a sample size of 512,658 hospitalized patients, this study used the nested multinomial logit model (NMNL) to estimate the impact of COH on the medical outcomes.

Results

The patients were mainly elderly, with an average age of 66.28 years old. The average length of stay was 9.61 days. The female and male gender were split evenly. A high level of hospitals is positively and significantly associated with the death and transfer rates (p < 0.001), which may be related to more severe illness among patients in high COH.

Conclusion

The COH made a difference in the medical outcomes significantly. COH should be reasonably selected according to disease types to achieve the optimal medical outcome. So, China should promote the construction of a tiered delivery system.

Associations of hospital volume and hospital competition with short-term, middle-term and long-term patient outcomes after breast cancer surgery: a retrospective population-based study

OBJECTIVES

For oncological care, there is a clear tendency towards centralisation and collaboration aimed at improving patient outcomes. However, in market-based healthcare systems, this trend is related to the potential trade-off between hospital volume and hospital competition. We analyse the association between hospital volume, competition from neighbouring hospitals and outcomes for patients who underwent surgery for invasive breast cancer (IBC).

OUTCOME MEASURES

Surgical margins, 90 days re-excision, overall survival.

DESIGN, SETTING, PARTICIPANTS

In this population-based study, we use data from the Netherlands Cancer Registry. Our study sample consists of 136 958 patients who underwent surgery for IBC between 2004 and 2014 in the Netherlands.

RESULTS

Our findings show that treatment types as well as patient and tumour characteristics explain most of the variation in all outcomes. After adjusting for confounding variables and intrahospital correlation in multivariate logistic regressions, hospital volume and competition from neighbouring hospitals did not show significant associations with surgical margins and re-excision rates. For patients who underwent surgery in hospitals annually performing 250 surgeries or more, multilevel Cox proportional hazard models show that survival was somewhat higher (HR 0.94). Survival in hospitals with four or more (potential) competitors within 30 km was slightly higher (HR 0.97). However, this effect did not hold after changing this proxy for hospital competition.

CONCLUSIONS

Based on the selection of patient outcomes, hospital volume and regional competition appear to play only a limited role in the explanation of variation in IBC outcomes across Dutch hospitals. Further research into hospital variation for high-volume tumours like the one studied here is recommended to (i) use consistently measured quality indicators that better reflect multidisciplinary clinical practice and patient and provider decision-making, (ii) include more sophisticated measures for hospital competition and (iii) assess the entire process of care within the hospital, as well as care provided by other providers in cancer networks.

Impact of Competition Versus Centralisation of Hospital Care on Process Quality: A Multilevel Analysis of Breast Cancer Surgery in France

BACKGROUND

The implications of competition among hospitals on care quality have been the subject of considerable debate. On one hand, economic theory suggests that when prices are regulated, quality will be increased in competitive markets. On the other hand, hospital mergers have been justified by the need to exploit cost advantages, and by evidence that hospital volume and care quality are related.

METHODS

Based on patient-level data from two years (2005 and 2012) we track changes in market competition and treatment patterns in breast cancer surgery. We focus on technology adoption as a proxy of process quality and examine the likelihood of offering two innovative surgical procedures: immediate breast reconstruction (IBR), after mastectomy and sentinel lymph node biopsy (SLNB). We use an index of competition based on a multinomial logit model of hospital choice which is not subject to endogeneity bias, and estimate its impact on the propensity to receive IBR and SLNB by means of multilevel models taking into account both observable patient and hospital characteristics.

RESULTS

The likelihood of receiving these procedures is significantly higher in hospitals located in more competitive markets. Yet, hospital volume remains a significant indicator of quality, therefore benefits of competition appear to be sensitive to the estimates of the impact of volume on care process. In France, the centralisation policy, with minimum activity thresholds, have contributed to improving breast cancer treatment between 2005 and 2012.

CONCLUSION

Finding the right balance between costs and benefits of market competition versus concentration of hospital care supply is complex. We find that close to monopolistic markets do not encourage innovation and quality in cancer treatment, but highly competitive markets where many hospitals have very low activity volumes are also problematic because hospital quality is positively linked to patient volume.

Heterogeneous effects of hospital competition on inpatient expenses: an empirical analysis of diseases grouping basing on conditions' complexity and urgency

Background

Multiple pro-competition policies were implemented during the new round of healthcare reform in China. Differences in conditions’ complexity and urgency across diseases associating with various degrees of information asymmetry and choice autonomy in the process of care provision, would lead to heterogeneous effects of competition on healthcare expenses. However, there are limited studies to explore it. This study aims to examine the heterogeneous effects of hospital competition on inpatient expenses basing on disease grouping according to conditions’ complexity and urgency.

Methods

Collecting information from discharge data of inpatients and hospital administrative data of Sichuan province in China, we selected representative diseases. K-means clustering was used to group the selected diseases and Herfindahl-Hirschman Index (HHI) was calculated based on the predicted patient flow to measure the hospital competition. The log-linear multivariate regression model was used to examine the heterogeneous effects of hospital competition on inpatient expenses.

Results

We selected 19 representative diseases with significant burdens (more than 1.1 million hospitalizations). The selected diseases were divided into three groups, including diseases with highly complex conditions, diseases with urgent conditions, and diseases with less complex and less urgent conditions. For diseases with highly complex conditions and diseases with urgent conditions, the estimated coefficients of HHI are mixed in the direction and statistical significance in the identical regression model at the 5% level. For diseases with less complex and less urgent conditions, the coefficients of HHI are all positive, and almost all of them significant at the 5% level.

Conclusions

We found heterogeneous effects of hospital competition on inpatient expenses across disease groups: hospital competition does not play an ideal role in reducing inpatient expenses for diseases with highly complex conditions and diseases with urgent conditions, but it has a significant effect in reducing inpatient expenses of diseases with less complex and less urgent conditions. Our study offers implications that the differences in condition’s complexity and urgency among diseases would lead to different impacts of hospital competition, which would be given full consideration when designing the pro-competition policy in the healthcare delivery system to achieve the desired goal.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07331-1.

Risk factors for increased COVID-19 case-fatality in the United States: A county-level analysis during the first wave

The ongoing COVID-19 pandemic is causing significant morbidity and mortality across the US. In this ecological study, we identified county-level variables associated with the COVID-19 case-fatality rate (CFR) using publicly available datasets and a negative binomial generalized linear model. Variables associated with decreased CFR included a greater number of hospitals per 10,000 people, banning religious gatherings, a higher percentage of people living in mobile homes, and a higher percentage of uninsured people. Variables associated with increased CFR included a higher percentage of the population over age 65, a higher percentage of Black or African Americans, a higher asthma prevalence, and a greater number of hospitals in a county. By identifying factors that are associated with COVID-19 CFR in US counties, we hope to help officials target public health interventions and healthcare resources to locations that are at increased risk of COVID-19 fatalities.

Regulating Hospital Prices Based On Market Concentration Is Likely To Leave High-Price Hospitals Unaffected

Concern about high hospital prices for commercially insured patients has motivated several proposals to regulate these prices. Such proposals often limit regulations to highly concentrated hospital markets. Using a large sample of 2017 US commercial insurance claims, we demonstrate that under the market definition commonly used in these proposals, most high-price hospitals are in markets that would be deemed competitive or "moderately concentrated," using antitrust guidelines. Limiting policy actions to concentrated hospital markets, particularly when those markets are defined broadly, would likely result in poor targeting of high-price hospitals. Policies that target the undesired outcome of high price directly, whether as a trigger or as a screen for action, are likely to be more effective than those that limit action based on market concentration.

The Comparison Between Different Hospital Market Definition Approaches: An Empirical Analysis of 11 Representative Diseases in Sichuan Province, China

Objective: This study aims to provide empirical evidence for the controversy about whether the inference is consistent if alternative hospital market definition methods are employed, and for which definition method is the best alternative to the predicted patient flow approach.

Data sources: Collecting data from the discharge data of inpatients and hospital administrative data of Sichuan province in China in the fourth quarter of 2018.

Study Design: We employed Herfindahl–Hirschman Index (HHI) as the proxy of market competition used as an example to measure the hospital market structure. Correlation coefficients of HHIs based on different definition methods were assessed. The corresponding coefficient of each HHI estimated in identical regression models was then compared. In addition, since the predicted patient flow method has been argued by the literature of its advantages compared with the previous approaches, we took the predicted patient flow as a reference to compare with the other approaches.

Data Extraction Methods: We selected the common diseases with a significant burden, and 11 diseases were included (902,767 hospitalizations).

Principal Findings: The correlation coefficients of HHIs based on different market definition methods are all significantly greater than 0, and the coefficients of HHIs are different in identical regression models. Taking the predicted patient flow approach as a reference, we found that the correlation coefficients between HHIs based on fixed radius and predicted patient flow approach is larger than others, and their parameter estimates are all consistent.

Conclusion: Although the HHIs based on different definition methods are significantly and positively correlated, the inferences about the effectiveness of market structure would be inconsistent when alternative market definition methods are employed. The fixed radius would be the best alternative when researchers want to use the predicted patient flow method to define the hospital market but are hindered by the data limitations and computational complexity.

Hospital competition in a national health service: Evidence from a patient choice reform

We study the impact of exposing hospitals in a National Health Service (NHS) to non-price competition by exploiting a patient choice reform in Norway in 2001. The reform facilitates a difference-in-difference approach due to plausibly exogenous (geographical) variation in pre-reform market structure. Employing rich, administrative data, covering the universe of hospital admissions from 1998 to 2005, we estimate models with hospital and treatment (DRG) fixed-effects and use only emergency admissions to limit patient selection issues. The results show that hospitals in more competitive areas have a sharper reduction in AMI mortality but no effect on stroke mortality. We also find that exposure to competition reduces all-cause mortality, shortens length of stay, but increases readmissions, though the effects are small in magnitude. In years with high (DRG) prices, the negative effect on readmissions almost vanishes. Finally, exposure to competition tends to reduce waiting times and increase admissions, but the effects must be interpreted with care as the outcomes include elective treatments.

Hospital market competition and health technology diffusion: An empirical study of laparoscopic appendectomy in China

The evidence about the role of hospital market competition on health technology diffusion in developing countries is scarce. In this study, we examined the association between hospital market competition and the diffusion of health technologies in China's healthcare system. Laparoscopic appendectomy, a minimally invasive surgery for patients with acute appendicitis, was selected as a representative of cost-effective health technology. The inpatient discharge dataset linked to the annually hospital administrative data and to the demographic and socioeconomic data were used. A total of 261,922 patients who were diagnosed with acute appendicitis and had received either open appendectomy or laparoscopic appendectomy at 820 hospitals in Sichuan, China between 2017 and 2019 were included in our analyses. Our outcome measure was the use of laparoscopic appendectomy during hospitalization. We accounted for the endogeneity of hospital competition measures using the Herfindahl-Hirschman Index calculated by predicted patient flows. Controlling for the observable patient, hospital and region characteristics, multivariate logistic regression was performed to model the association between hospital competition and the diffusion of laparoscopic appendectomy. The rapid diffusion of laparoscopic appendectomy over the study period and the substantial variation in use across regions and hospitals were observed. The regression results showed that laparoscopic appendectomy diffused faster in the markets where hospitals faced more competition. Our findings suggest that the diffusion of laparoscopic appendectomy is not only driven by medical factors but also nonmedical factors like hospital market competition. Our study provides new evidence on the association between market structure and technology diffusion in China's hospital market and offers the implications of appropriate technologies diffusion in health for policymakers.

Divided by choice? For-profit providers, patient choice and mechanisms of patient sorting in the English National Health Service

This paper studies patient choice of provider following government reforms in the 2000s, which allowed for-profit surgical centers to compete with existing public National Health Service (NHS) hospitals in England. For-profit providers offer significant benefits, notably shorter waiting times. We estimate the extent to which different types of patients benefit from the reforms, and we investigate mechanisms that cause differential benefits. Our counterfactual simulations show that, in terms of the value of access, entry of for-profit providers benefitted the richest patients twice as much as the poorest, and white patients six times as much as ethnic minority patients. Half of these differences is explained by healthcare geography and patient health, while primary care referral practice plays a lesser, though non-negligible role. We also show that, with capitated reimbursement, different compositions of patient risks between for-profit surgical centers and existing public hospitals put public hospitals at a competitive disadvantage.

Patient selection in the presence of regulatory oversight based on healthcare report cards of providers: the case of organ transplantation

Many healthcare report cards provide information to consumers but do not represent a constraint on the behavior of healthcare providers. This is not the case with the report cards utilized in kidney transplantation. These report cards became more salient and binding, with additional oversight, in 2007 under the Centers for Medicare and Medicaid Services Conditions of Participation. This research investigates whether the additional oversight based on report card outcomes influences patient selection via waiting-list registrations at transplant centers that meet regulatory standards. Using data from a national registry of kidney transplant candidates from 2003 through 2010, we apply a before-and-after estimation strategy that isolates the impact of a binding report card. A sorting equilibrium model is employed to account for center-level heterogeneity and the presence of congestion/agglomeration effects and the results are compared to a conditional logit specification. Our results indicate that patient waiting-list registrations change in response to the quality information similarly on average if there is additional regulation or not. We also find evidence of congestion effects when spatial choice sets are smaller: new patient registrations are less likely to occur at a center with a long waiting list when fewer options are available.

Risk factors for increased COVID-19 case-fatality in the United States: A county-level analysis during the first wave

The ongoing COVID-19 pandemic is causing significant morbidity and mortality across the US. In this ecological study, we identified county-level variables associated with the COVID-19 case-fatality rate (CFR) using publicly available datasets and a negative binomial generalized linear model. Variables associated with decreased CFR included a greater number of hospitals per 10,000 people, banning religious gatherings, a higher percentage of people living in mobile homes, and a higher percentage of uninsured people. Variables associated with increased CFR included a higher percentage of the population over age 65, a higher percentage of Black or African Americans, a higher asthma prevalence, and a greater number of hospitals in a county. By identifying factors that are associated with COVID-19 CFR in US counties, we hope to help officials target public health interventions and healthcare resources to locations that are at increased risk of COVID-19 fatalities.

What drives different treatment choices? Investigation of hospital ownership, system membership and competition

BACKGROUND

Differences in ownership types have attracted considerable interest because of policy implications. Moreover, competition in hospital markets is promoted to reduce health care spending. However, the effects of system membership and competition on treatment choices of hospitals have not been considered in studying hospital ownership types. We examine the treatment choices of hospitals considering ownership types (not-for-profit, for-profit, and government), system membership, patient insurance status (insured, and uninsured) and hospital competition in the United States.

METHODS

We estimate the probability of according the procedure as the treatment employing logistic regression. We consider all procedures accorded at hospitals, controlling for procedure type and diagnosis as well as relevant patient and hospital characteristics. Competition faced by hospitals is measured using a distance-weighted approach separately for procedural groups. Patient records are obtained from State Inpatient Databases for 11 states and hospital characteristics come from American Hospital Association Annual Survey.

RESULTS

Not-for-profit hospitals facing low for-profit competition that are nonmembers of hospital systems, act like government hospitals, whereas not-for-profits facing high for-profit competition and system member not-for-profits facing low for-profit competition are not statistically significantly different from their for-profit counterparts in terms of treatment choices. Uninsured patients are on average 7% less likely to be accorded the procedure as the treatment at system member not-for-profit hospitals facing high for-profit competition than insured patients. System member not-for-profit hospitals, which account for over half of the observations in the analysis, are on average 16% more likely to accord the procedure as the treatment when facing high for-profit competition than low-for-profit competition.

CONCLUSIONS

We show that treatment choices of hospitals differ by system membership and the level of for-profit competition faced by the hospitals in addition to hospital ownership type and health insurance status of patients. Our results support that hospital system member not-for-profits and not-for-profits facing high for-profit competition are for-profits in disguise. Therefore, system membership is an important characteristic to consider in addition to market competitiveness when tax exemption of not-for-profits are revisited. Moreover, higher competition may lead to increasing health care costs due to more aggressive treatment choices, which should be taken into account while regulating hospital markets.

Hospital Competition and Unplanned Readmission: Evidence from a Systematic Review

Competition has been widely introduced among hospitals in the hope of improving health-care quality. However, whether competition leads to higher-quality health care is a topic of considerable debate. We conducted a systematic review to assess the impact of hospital-market competition on unplanned readmission. We searched six electronic databases (PubMed, EmBase, Wiley Online Library, Web of Science, Scopus, and JSTOR) and reference lists of screened articles for relevant studies, and strictly followed methods proposed by the Cochrane Collaboration. Finally, nine observational studies with 2,241,767 patients were included. For the primary outcome, pooled results of three studies showed that it was uncertain whether or not hospital competition reduces readmission (β=0.02, P=0.06; very low certainty of evidence, as they were all observational studies with high heterogeneity). Inconsistent results were found in the remaining six studies, and they were assessed as very low–certainty evidence, downgraded for either inconsistency or indirectness or both. As for secondary outcomes, seven of the nine studies reported on the impact of competition on the risk of mortality, and two reported on length of stay (LOS). It was uncertain whether competition had an effect on mortality or LOS. The relevant studies were limited and of very low certainty, which means there is currently no reliable evidence showing that hospital competition reduces quality of health care in terms of readmission/mortality/LOS. There is a need for rigorous studies to assess the impact of hospital competition on the quality of health care.

Payment Arrangements for Private Healthcare Purchasing Under Publicly Funded Systems in Low- and Middle-Income Countries: Issues and Implications

This paper examines private healthcare purchasing under publicly financed health systems in low- and middle-income countries (LMICs) to argue that the payment methods and rates applied to private and public health providers need careful attention to ensure equity, efficiency and quality in healthcare service provision. Specifically, public purchasers should develop a clear mechanism to establish justifiable payment rates for the purchase of private health services under publicly funded systems, using cost information and appropriate engagement with private health providers. In order to determine the validity of payment arrangements with private providers, clarification of the shared roles and responsibilities of public and private healthcare providers is required, including specification of types of services to be delivered by public and private providers, and the services for which public providers receive government budget and salaries above payments for other publicly funded services. In addition, carefully designed payment methods should include incentives to encourage healthcare providers to deliver efficient, equitable and quality health services, which requires consideration of how the healthcare purchasing market is structured. Furthermore, governments should establish sound legal frameworks to ensure that public purchasers establish 'strategic' payment arrangements with healthcare providers and that healthcare providers are able to respond to the incentives sent by the payment arrangements. To deepen understanding of public purchasing of private healthcare services and gain further insight in the LMIC context, in-depth empirical studies are necessary on the payment methods and rates used by public purchasers in a range of settings and the implications of payment arrangements on efficiency, equity and quality in healthcare service provision.

The Evolving Hospital Market in China After the 2009 Healthcare Reform

Since the initiation of national healthcare reform in 2009, China’s hospital market has witnessed significant change. To provide a brief description about its evolving process, China Health Statistical Yearbook data and Sichuan administrative data from 2009 to 2017 were used in this article. An overall upward trend of hospital delivery capacity was found in this study, which increased from 3.12 million beds and 1.09 million doctors in 2009 to 6.12 million and 1.80 million in 2017, respectively, while the primary healthcare institutions presented fairly slow development pace. Growing proportion of medical resources and patients gathered in hospitals, especially tertiary hospitals. While private hospitals demonstrated an increasingly important role in hospital market with growing share of capacity and service, their average capacity, especially the human resource, was found to be much lower than that of public hospitals and the gaps are still widening. The competition among hospitals grouped by homogeneous ownership types has predominated the increasingly intensified hospital market competition in China. In order to adapt to the raising demand of health care in China, it is highly recommended that strategies forged at governmental levels be focused on primary care promotion, guiding the development of private hospitals as well as on promoting orderly competition in the hospital market.

The Effects of Market Competition on Cardiologists' Adoption of Transcatheter Aortic Valve Replacement

BACKGROUND

For decades, the prevailing assumption regarding the diffusion of high-cost medical technologies has been that competitive markets favor more aggressive adoption of new treatments by health care providers (ie, the "Medical Arms Race"). However, novel regulations governing the adoption of transcatheter aortic valve replacement (TAVR) may have disrupted this paradigm when TAVR was introduced.

OBJECTIVE

The objective of this study was to assess the relationship between the market concentration of physician group practices and the adoption of TAVR in its first years of use.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

Physician group practices (n=5116) providing interventional cardiology services in the United States from May 1, 2012, to December 31, 2014.

MEASURES

The first use of TAVR as indicated by a fee-for-service Medicare claim. Covariates including characteristics of the physician groups (ie, case volume, hospital affiliation, mean patient risk) as well as county-level and market-level characteristics.

RESULTS

By the close of 2014, 9.3% of practices had adopted TAVR. Cox proportional hazards models revealed a hazard ratio of 1.26 (95% confidence interval: 1.16-1.37, P<0.001) per 1000 point increase in the physician group practice Herfindahl-Hirschman Index, indicating each 1000 point increase in group practice Herfindahl-Hirschman Index was associated with a 26% relative increase in the rate of TAVR adoption.

CONCLUSIONS

Adoption of TAVR by physician groups in concentrated markets was potentially a consequence of the unique regulations governing TAVR reimbursement, which favored the adoption of TAVR by physician groups with greater market power. These findings have important implications for how future regulations may shape patterns of technology adoption.

Perceived Competition and Process of Care in Rural China

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Does price deregulation in a competitive hospital market damage quality?

Regulators may be hesitant to permit price competition in healthcare markets because of its potential to damage quality. We assess whether this fear is well founded by examining a reform that permitted Dutch health insurers to freely negotiate prices with hospitals. Unlike previous research on hospital competition that has relied on quality indicators for urgent treatments, we take advantage of a plausible absence of selection bias to identify the effect on the quality of elective procedures that should be more price responsive. Using data on all admissions for hip replacements to Dutch hospitals and a difference-in-differences comparison between more and less concentrated markets, we find no evidence that price deregulation in a competitive environment reduces quality measured by hip replacement readmission rates.

Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms

Policies aiming to spur quality competition among health care providers are ubiquitous, but their impact on quality is ex ante ambiguous, and credible empirical evidence is lacking in many contexts. This study contributes to the sparse literature on competition and primary care quality by examining recent competition enhancing reforms in Sweden. The reforms aimed to stimulate patient choice and entry of private providers across the country but affected markets differently depending on the initial market structure. We exploit the heterogeneous impact of the reforms in a difference-in-differences strategy, contrasting more and less exposed markets over the period 2005-2013. Although the reforms led to substantially more entry of new providers in more exposed markets, the effects on primary care quality were modest: We find small improvements of patients' overall satisfaction with care, but no consistently significant effects on avoidable hospitalisation rates or satisfaction with access to care. We find no evidence of economically meaningful quality reductions on any outcome measure.

The Effect of Hospital Market Competition on the Adoption of Transcatheter Aortic Valve Replacement

BACKGROUND

The use of transcatheter aortic valve replacement (TAVR) has grown rapidly. The purpose of this study was to assess whether hospital market competition was associated with the use of TAVR.

METHODS

We used 5 Healthcare Cost and Utilization Project state inpatient databases (Arizona, Florida, Iowa, Massachusetts, Washington) to identify patients undergoing TAVR (n = 5563) or surgical aortic valve replacement (n = 30,672) across 154 hospitals from 2011 to 2014. Using the Herfindahl-Hirschman Index (HHI) to calculate market competition, hospitals were categorized into commonly used categories of low (HHI >0.25), moderate (HHI 0.15-0.25), and high (HHI <0.15) competition. We associated market competition category with TAVR utilization using hierarchical logistic regression, adjusting for patient characteristics, hospital characteristics, year, and hospital random effect. We modeled associations between HHI category and in-hospital mortality, admission length of stay, and discharge to home as secondary outcomes.

RESULTS

After adjustment, patients treated at high-competition hospitals had higher odds of receiving TAVR, relative to patients at low-competition hospitals (adjusted odds ratio [ORadj], 5.31; 95% confidence interval [CI], 2.10-13.4). TAVR use increased each year (ORadj, 1.73; 95% CI, 1.38-2.17) but was similar across HHI categories. Competition was not associated with in-hospital mortality or length of stay. Patients at high-competition hospitals were more likely to be discharged home (ORadj, 2.39; 95% CI, 1.23-4.66) compared with patients at low-competition hospitals.

CONCLUSIONS

Market competition was positively associated with a hospital's adoption of TAVR. Future studies should further examine the impact of competition on quality and appropriateness.

Hospitals accreditation status in Indonesia: associated with hospital characteristics, market competition intensity, and hospital performance?

Background

Hospital accreditation is widely adopted as a visible measure of an organisation’s quality and safety management standards compliance. There is still inconsistent evidence regarding the influence of hospital accreditation on hospital performance, with limited studies in developing countries. This study aims to explore the association of hospital characteristics and market competition with hospital accreditation status and to investigate whether accreditation status differentiate hospital performance.

Methods

East Java Province, with a total 346 hospitals was selected for this study. Hospital characteristics (size, specialty, ownership) and performance indicator (bed occupancy rate, turnover interval, average length of stay, gross mortality rate, and net mortality rate) were retrieved from national hospital database while hospital accreditation status were recorded based on hospital accreditation report. Market density, Herfindahl-Hirschman index (HHI), and hospitals relative size as competition indicators were calculated based on the provincial statistical report data. Logistic regression, Mann-Whitney U-test, and one sample t-test were used to analyse the data.

Results

A total of 217 (62.7%) hospitals were accredited. Hospital size and ownership were significantly associated with of accreditation status. When compared to government-owned, hospital managed by ministry of defense (B = 1.705, p = 0.012) has higher probability to be accredited. Though not statistically significant, accredited hospitals had higher utility and efficiency indicators, as well as higher mortality.

Conclusions

Hospital with higher size and managed by government have higher probability to be accredited independent to its specialty and the intensity of market competition. Higher utility and mortality in accredited hospitals needs further investigation.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4187-x) contains supplementary material, which is available to authorized users.

Quality-based ratings in Medicare and trends in kidney transplantation

OBJECTIVE

To assess the relationship between the 2007 Medicare regulation enforcing quality standards for transplant centers and trends in kidney transplantation.

DATA SOURCES

Transplant centers' biannual reports and the national registry for kidney transplantation from 2003 to 2010.

STUDY DESIGN

Non-compliant (low-performing) centers were compared with centers in compliance with quality standards according to: number of transplants, waiting-list registrations, and rates of graft failures, transfers, and deaths. Multivariate regressions were estimated to evaluate the association between the regulation and transplantation outcomes.

DATA EXTRACTION METHODS

Patient characteristics and outcomes were aggregated to six-month periods and linked to centers' reports.

PRINCIPAL FINDINGS

Relative to average-performing centers, 12 percent of transplants shifted away from low-performing centers and high-performing centers captured 6 percent of this decline. Low-performing centers experienced a 2-percentage point per period decline in 1-year graft failure rates and a 15-percent decrease in registrations post-regulation, whereas high-performing centers incurred a 5-percent decrease in registrations relative to average-performing centers.

CONCLUSIONS

Government oversight in kidney transplantation was associated with a small downward shift in overall kidney transplants. Reductions in graft failure rates at low-performing centers may imply an increase in quality or a decline in transplantation of either marginal organs or riskier patients; whereas reductions in registrations may indicate risk aversion toward high-risk patients. Policy makers should consider making less punitive requirements for programs, which employ new transplantation techniques to expand access.

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

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

The relationship of hospital market concentration, costs, and quality for major surgical procedures

BACKGROUND

Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care.

METHODS

Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques.

RESULTS

A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection.

CONCLUSION

In less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs.

Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework

Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.

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

There is much debate about the effect of competition in healthcare and especially the effect of competition on the quality of healthcare, although empirical evidence on this subject is mixed. The Netherlands provides an interesting case in this debate. The Dutch system could be characterized as a system involving managed competition and mandatory healthcare insurance. Information about the quality of care provided by hospitals has been publicly available since 2008. In this paper, we evaluate the relationship between quality scores for three diagnosis groups and the market power indicators of hospitals. We estimate the impact of competition on quality in an environment of liberalized pricing. For this research, we used unique price and production data relating to three diagnosis groups (cataract, adenoid and tonsils, bladder tumor) produced by Dutch hospitals in the period 2008-2011. We also used the quality indicators relating to these diagnosis groups. We reveal a negative relationship between market share and quality score for two of the three diagnosis groups studied, meaning that hospitals in competitive markets have better quality scores than those in concentrated markets. We therefore conclude that more competition is associated with higher quality scores.

Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study

Background

There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical cancer services. Previous evidence has shown that patients are prepared to bypass their nearest cancer centre to receive surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using prostate cancer surgery as a model.

Methods

We mapped all patients in England who underwent radical prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical prostatectomy service.

Findings

Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical prostatectomy at an NHS provider in England. Of the 65 radical prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical prostatectomy service during the study period. Radical prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014.

Interpretation

Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable cancer care.

Funding

National Institute for Health Research.

Does Competition Have an Effect on Price and Quality in Physiotherapy?

We estimate the effect of competition on quality and prices in physiotherapy organised and financed by the Social Insurance Institution of Finland for disabled individuals. Within the physiotherapy market, firms participate in competitive bidding, prices are determined by the market, services are free at the point of use and firms are allowed to react to patient choice only by enhancing quality. Firm-level data (n = 854) regarding quality and price were analysed. Using 2SLS estimation techniques, we analysed the relationship between quality and competition, and price and competition. Our study found that competition has a negative (yet weak) effect on quality. Prices on the other hand are not affected by competition. The result is likely caused by imperfect information, because it seems that the Social Insurance Institution of Finland has provided too little information for patients to make adequate choices about proper service providers. We argue that by publishing quality information, it is possible to ease the decision-making of patients and influence the quality strategies of firms active in the physiotherapy market. Moreover, we found that competition appeared as an exogenous variable in this study. Copyright © 2016 John Wiley & Sons, Ltd.

The Volume-Outcome Relationship Revisited: Practice Indeed Makes Perfect

OBJECTIVE

To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes.

DATA SOURCES

We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals' addresses and the zip codes of patients' place of residence.

STUDY DESIGN

We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital.

PRINCIPAL FINDINGS

Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality.

CONCLUSIONS

We provide evidence for the practice-makes-perfect hypothesis by showing that volume is a driving factor for quality.

Do hospitals respond to rivals' quality and efficiency? A spatial panel econometric analysis

We investigate whether hospitals in the English National Health Service change their quality or efficiency in response to changes in quality or efficiency of neighbouring hospitals. We first provide a theoretical model that predicts that a hospital will not respond to changes in the efficiency of its rivals but may change its quality or efficiency in response to changes in the quality of rivals, though the direction of the response is ambiguous. We use data on eight quality measures (including mortality, emergency readmissions, patient reported outcome, and patient satisfaction) and six efficiency measures (including bed occupancy, cancelled operations, and costs) for public hospitals between 2010/11 and 2013/14 to estimate both spatial cross-sectional and spatial fixed- and random-effects panel data models. We find that although quality and efficiency measures are unconditionally spatially correlated, the spatial regression models suggest that a hospital's quality or efficiency does not respond to its rivals' quality or efficiency, except for a hospital's overall mortality that is positively associated with that of its rivals. The results are robust to allowing for spatially correlated covariates and errors and to instrumenting rivals' quality and efficiency.

Does hospital ownership influence hospital referral region health rankings in the United States

Extensive evidence demonstrates that a hospital's organizational ownership structure impacts its overall performance, but little is known concerning the influence of hospital structure on the health of its community. This paper explores the association between US hospital referral region (HRR) health rankings and hospital ownership and performance. Data from the 2016 Commonwealth Fund Scorecard on Local Health System Performance, the American Hospital Association dataset, and the Hospital Value-Based Purchasing dataset are utilized to conduct a cross-sectional analysis of 36 quality measures across 306 HRRs. Multivariate regression analysis was used to estimate the association among hospital ownership, system performance measures-access and affordability, prevention and treatment, avoidable hospital use and cost, and healthy lives-and performance as measured by value-based purchasing total performance scores. We found that indicators of access and affordability, as well as prevention and treatment, were significantly associated across all 3 hospitals' organizational structures. Hospital referral regions with a greater number of not-for-profit hospitals demonstrated greater indications of access and affordability, as well as better prevention and treatment rankings than for-profit and government hospitals. Hospital referral regions with a greater number of government, nonfederal hospitals had worse scores for healthy lives. Furthermore, the greater the total performance scores score, the better the HRR score on prevention and treatment rankings. The greater the per capita income, the better the score across all 4 dimensions. As such, this inquiry supports the assertion that performance of a local health system is dependent on its community's resources of health care delivery entities and their structure.

The Effect of Physician and Hospital Market Structure on Medical Technology Diffusion

OBJECTIVE

To examine the influence of physician and hospital market structures on medical technology diffusion, studying the diffusion of drug-eluting stents (DESs), which became available in April 2003.

DATA SOURCES/STUDY SETTING

Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey.

STUDY DESIGN

Retrospective claims data analyses.

DATA COLLECTION/EXTRACTION METHODS

All fee-for-service Medicare beneficiaries who received a percutaneous coronary intervention (PCI) with a cardiac stent in 2003 or 2004. Each PCI record was joined to characteristics on the patient, the procedure, the cardiologist, and the hospital where the PCI was delivered. We accounted for the endogeneity of physician and hospital market structure using exogenous variation in the distances between patient, physician, and hospital locations. We estimated multivariate linear probability models that related the use of a DES in the PCI on market structure while controlling for patient, physician, and hospital characteristics.

PRINCIPAL FINDINGS

DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered.

CONCLUSIONS

Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly.

Competition and quality in a physiotherapy market with fixed prices

Our study focuses on competition and quality in physiotherapy organized and regulated by the Social Insurance Institution of Finland (Kela). We first derive a hypothesis with a theoretical model and then perform empirical analyses of the data. Within the physiotherapy market, prices are regulated by Kela, and after registration eligible firms are accepted to join a pool of firms from which patients choose service providers based on their individual preferences. By using 2SLS estimation techniques, we analyzed the relationship among quality, competition and regulated price. According to the results, competition has a statistically significant (yet weak) negative effect (p = 0.019) on quality. The outcome for quality is likely caused by imperfect information. It seems that Kela has provided too little information for patients about the quality of the service.

Effectiveness of weight loss intervention in highly-motivated people

A variety of approaches have been implemented to address the rising obesity epidemic, with limited success. I consider the success of weight loss efforts among a group of highly motivated people: those required to lose weight in order to qualify for a life-saving kidney transplantation. Out of 246 transplantation centers, I identified 156 (63%) with explicit body mass index (BMI) requirements for transplantation, ranging from 30 to 50kg/m². Using the United States national registry of transplant candidates, I examine outcomes for 29,608 obese deceased-donor transplant recipients between 1990 and 2010. I use value-added models to deal with potential endogeneity of center choice, in addition to correcting for sample selection bias arising from focusing on transplant recipients. Outcome variables measure BMI level and weight change (in BMI) between initial listing and transplantation. I hypothesize that those requiring weight loss to qualify for kidney transplantation will be most likely to lose weight. I find that the probability of severe and morbid obesity (BMI≥35kg/m²) decreases by 4 percentage points and the probability of patients achieving any weight loss increases by 22 percentage points at centers with explicit BMI eligibility criteria. Patients are also 13 percentage points more likely to accomplish clinically relevant weight loss of at least 5% of baseline BMI by transplantation at these centers. Nonetheless, I estimate an average decrease in BMI of only 1.7kg/m² for those registered at centers with BMI requirements. Further analyses suggest stronger intervention effects for patients whose BMI at listing exceeds thresholds as the distance from their BMI to the thresholds increases. Even under circumstances with great potential returns for weight loss, transplant candidates exhibit modest weight-loss. This suggests that, even in high-stakes environments, weight loss remains a challenge for the obese, and altering individual incentives may not be sufficient.

Research on the Hospital Market: Recent Advances and Continuing Data Needs

Research focused on the hospital market has been instrumental in furthering our understanding of the role of competition in health care. Such research would not have been conducted without the extensive public use data that have been made available to researchers. In particular, path-breaking studies were made possible thanks to access to Medicare and state all-payer discharge data. This paper describes recent advances in our understanding of hospital competition and speculates about what we could learn if additional data were available.