Does quality influence choice of general practitioner? An analysis of matched doctor–patient panel data

The impact of quality on the demand facing health care providers has important implications for the industrial organization of health care markets. In this paper we study the consumers' choice of general practitioner (GP), assuming they are unable to observe the true quality of GP services. A panel data set for 484 Norwegian GPs, with summary information on their patient stocks, renders the opportunity to identify and measure the impact of GP quality on the demand, accounting for patient health heterogeneity. We apply a multi-equation model in the LISREL format, with GP quality and patient health as latent determinants of demand for GP services. Patient excess mortality rate at the GP level is one indicator of quality. Our results indicate that GP quality has a clear positive effect on demand, even when patient heterogeneity is accounted for.     

Competition and physician-enabled demand: The role of managed care

Recent organizational changes in the health care sector promote greater patient participation in their treatment decisions. How physicians respond to patient-initiated requests for treatment is an issue of considerable policy interest. To study this phenomenon, we introduce the notion of physician-enabled demand and examine empirically whether this behavior responds to competitive pressures in the market and financial incentives associated with different physician payment mechanisms.We find that physician-enabled demand increases with more competition under fee-for-service reimbursement, but decreases with greater competition under managed care. This asymmetric response is quite consistent with our conceptual framework and at odds with alternative interpretations.     

The Impact of the NHS Reforms on Queues and Surgical Outcomes in England: Evidence From Hip Fracture Patients

National Health Service (NHS) reform introduced incentives for efficiency and cost effectiveness, yet little is known about their effectiveness in reducing waiting times for surgery or improving post-surgical outcomes. This paper finds that waiting times for hip fracture surgery declined after the NHS reforms, and patients were more likely to be discharged to another provider. However, hospitals have not simply shifted the burden of care to other providers, since lengths of stay ending in a discharge to home fell. The effect of wait time on surgical outcomes is small in magnitude and cannot explain the post-reform improvements in outcomes.     

Incentives and targets in hospital care: Evidence from a natural experiment

Performance targets are commonly used in the public sector, despite their well known problems when organisations have multiple objectives and performance is difficult to measure. It is possible that such targets may work where there is considerable consensus that performance needs to be improved. We investigate this possibility by examining the response of the English National Health Service to high profile waiting time targets. We exploit a natural policy experiment between two countries of the UK (England and Scotland) to establish the global effectiveness of the targets. We then use a within-England hospital analysis to confirm that responses vary by treatment intensity and to control for differences in resources which may accompany targets. We find that targets met their goals of reducing waiting times without diverting activity from other less well monitored aspects of health care and without decreasing patient health on exit from hospital.     

Multi-product costs and standby capacity derived from queuing theory: the case of Belgian hospitals

Empirical hospital cost function studies can be divided into two categories: studies estimating traditional multi-product cost functions and studies including demand uncertainty (assuming that hospitals provide standby capacity to cope with uncertain demand and stressing that the relationship between the uncertain demand, excess capacity and costs should be investigated). Most studies include (the inverse of) the occupancy rate in a relatively basic cost function. The first contribution of this paper is to incorporate an indicator of reserve capacity into a genuine multi-product cost function. The second contribution is to propose an alternative indicator to proxy the reserve margin. The often used occupancy rate has an important shortcoming: the same occupancy rate can hide different turnaway probabilities and waiting times, obscuring the true degree of reservation quality. Since turnaway probabilities and waiting times are typical queuing theory indicators, an indicator for average waiting time (derived from queuing theory) is incorporated into a proper multi-product cost function to capture the degree of standby capacity into a proper multi-product cost function. The study uses 1997 data on Belgian general care hospitals to estimate a multi-product cost function and calculate cost elasticities, marginal costs and the degree of economies of scale. The results further show that providing standby capacity has a significant impact on total costs.     

Patients, Doctors and Contracts: An Application of Principal-Agent Theory to the Doctor-Patient Relationship

The doctor-patient relationship has been the main focus of principal-agent theory in health care. This paper focuses on communication between doctors and patients within the doctor-patient relationship as a method by which the utility of the principal (patient) can be maximised. Patients' preferences for various attributes of the doctor‐patient relationship are examined using a discrete choice experiment. Individuals were presented with pairs of hypothetical scenarios describing GP visits that differed depending on the attributes of the doctor-patient relationship. In the time-constrained GP consultation, the results show that being able to talk to the doctor is the most important attribute, followed by patients' understanding of the doctor's explanations, waiting time for an appointment, and the amount of information transferred to the patient. Quality of information is more important than its quantity. The extent to which patients were involved in decision making had no influence on the choice of visit, although it was important to patients who were relatively young and female. Policies aimed at involving patients in decision making should be targeted at specific groups of patients only. The results have implications for the training of doctors in communication skills as a response to market failure caused by asymmetry of information.     

Competition and waiting times in hospital markets

This paper studies the impact of hospital competition on waiting times. We use a Salop-type model, with hospitals that differ in (geographical) location and, potentially, waiting time, and two types of patients: high-benefit patients who choose between neighbouring hospitals (competitive segment), and low-benefit patients who decide whether or not to demand treatment from the closest hospital (monopoly segment). Compared with a benchmark case of monopoly, we find that hospital competition leads to longer waiting times in equilibrium if the competitive segment is sufficiently large. Given a policy regime of hospital competition, the effect of increased competition depends on the parameter of measurement: Lower travelling costs increase waiting times, higher hospital density reduces waiting times, while the effect of a larger competitive segment is ambiguous. We also show that, if the competitive segment is large, hospital competition is socially preferable to monopoly only if the (regulated) treatment price is sufficiently high.     

More health care utilization with more insurance coverage? Evidence from a latent class model with German data

We analyse the impact of optional deductibles, private supplementary health insurance and income on the demand for health care utilization, measured as the number of physician visits with data from the German Socio-Economic Panel (SOEP). With a set of newly available variables for the years 2002, 2004 and 2006 that measure individual health more accurately and including risk-attitudes towards health we find that possible endogeneity of the insurance choice is not a problem. A latent class approach that takes into account the panel structure of the data reveals that especially individuals who have few doctor visits, the low users, respond strongest to insurance status and income. In this group we find that more insurance increases the demand for physician visits and there is a pro-rich inequity in health care utilization. No such effects are found for the high users.     

Can a Mixed Health Care System be Desirable on Equity Grounds?*

Should health care provision be public, private, or both? We consider this question in a setting where people differ in their earnings capacity and face some illness risk. We assume that illness reduces an individual's time endowment when waiting for treatment. Treatment can be obtained in a competitive private sector (through private insurance) or in the National Health Service (NHS) where it is provided free of charge but after some (endogenous) waiting time. The equilibrium in the health care sector consists of a waiting time in the NHS such that no patient wants to switch health care provider. This equilibrium is governed by two public policies: the income tax system and the size of the NHS. We find that: (i) a mixed system with a small NHS is never desirable; (ii) actuarially fair sickness insurance is never desirable either; (iii) a mixed system with a sufficiently large NHS may improve on a pure public system if the dispersion of earnings capacities is large enough; and (iv) the welfare gains from such a mixed system are not likely to be significant.     

Quality decreases from introducing patient choice in a National Health Service

Portuguese Economic Journal - A view often expressed about patient choice of health care providers is that it will increase competition between providers, which benefits the efficiency of the...     

健康投资的产业结构效应:来自OECD等国家的宏观证据

在"未富先病"以及"健康中国"的背景下,文章从产业结构出发,通过使用世界银行数据库和佩恩表1995-2011年百余个国家的面板数据,研究了健康投资行业的发展对经济结构的影响,以期为当下中国转型经济结构的时代诉求提供参考.研究结果显示:首先,发展健康投资行业有助于增加服务业就业人口比重,并且私人健康投资对增加服务业就业人口比重的影响系数大于公共健康投资;其次,相对于公共健康投资,私人健康投资对第二产业增加值的挤出效应更有限;第三,发展健康服务业,尤其是公共健康事业将加快经济结构转型速度.综上所述,发展健康产业对推进产业结构转型具有积极意义,但如何在政策效果和可能的阻力之间进行权衡还需要政策制定者的慎重考虑.     

Crossing the quality chasm: creating the ideal patient care experience

To create a health system that better meets patients' needs requires a fundamental redesign of our care delivery system and a new framework. Without a payment mechanism to reflect the value of care provided other than the face-to-face visit, adoption of advanced medical home principles will be challenging. The hand-off of the patient between providers and settings of care is a critical time for the patient and its effectiveness impacts patient care outcomes. The appropriate utilization of hospital and other health system resources is crucial, especially as hospitals, emergency departments, and other health care venues increasingly face capacity constraints and throughput challenges. It becomes the responsibility of the multidisciplinary team of providers to ensure that patients being discharged have an identified personal physician or team who will provide a medical home, and that the handoff to this medical home is thorough and well coordinated. An ideal patient care experience is one in which all systems and processes are geared to meet the needs of the patient: a safety-oriented system that provides standardized, evidence-based care supported by technology, but that recognizes and responds to individual needs.     

The effect of workforce issues on patient safety

The workforce of any health care organization is vital to its continued survival, but a highly competent and committed workforce is vital to its success. The evidence is clear: employees influence not only the financial performance of the organization, but also the safety and quality of the clinical care provided to patients. Health care organizations must understand these important linkages and have in place corporate strategies to manage workforce issues with a systems focus that ensures excellent leadership and operational processes, a healthy culture, and optimum patient outcomes. New levels of knowledge, resources, and implementation are needed to move health care in the United States to the next level of quality performance. Staff satisfaction and retention should be at the heart of the clinical improvement strategies. Such an approach will allow organizations to cope and thrive in an environment of workforce shortages and increasing consumer demand for quality. To quote Robert Waller, MD, of the Mayo Clinic, "The goal is the best care for every patient, every day. Our patients deserve nothing less.     

A fragmented patient safety concept: the structure and culture of safety management in health care

The uniform and visible commitment to safety management is a cultural and structural change that health care organizations have not typically attempted. Committee structures are just one example of how culture drives structure in managing health care safety. The question is: "Are we interested in making nonpatient safety programs as well understood and as culturally significant as patient safety programs?" Models exist to institutionalize safety management in health care. We need only look to the JCAHO or OSHA and other high-hazard industry models for examples of safety management. Change requires a focus on safety, not occupational safety or patient safety, but just safety. In health care, safety would be a key characteristic of organizational culture. The organizational expectation is then that all employees will work safely and practice safety. Employees will apply safe practices when handling chemicals, in lifting, and when giving medications. Only when safety imbues the work and decisions of each employee in this way will the highest level of safety be attained.     

Demand in New Zealand hospitals: expect the unexpected?

The health care sector in New Zealand has undergone substantial structural reform since 1983 and stands out relative to other OECD countries, with relatively low per capita health expenditure and a high share of public funding. Efficient allocation of resources in this public dominant health system is therefore paramount. This article uses a national database of hospital admissions to predict hospital demand. We find lagged information on patient demand imperative in formulating an easy to implement approach for predictive purposes. Contrasting predicted with actual demand, we construct an indicator of volatility in unexpected patient demand (at both the hospital and the disease chapter level) and assess its role with regard to patient outcomes. There is consistent evidence that when actual patient numbers exceed predicted, patients stay in hospital significantly longer and are more likely to have an acute readmission.     

FORECASTING THE DEMAND FOR HEALTH CARE IN OECD NATIONS AND CHINA

This article argues that the nations of the Organisation for Economic Co-operation and Development (OECD) are facing a potential disaster: intergenerational conflicts between the large number of workers approaching retirement at an earlier age than ever before in history and the smaller number entering the labor market. These nations are confronted with the choice of whether to default on commitments to pensions and health care, to reduce benefits, or to increase the taxes borne by younger workers. The author argues that this new intergenerational conflict is the result of technophysio evolution , a synergism between technological and physiological improvements that has produced a form of human evolution that is biological but not genetic, rapid, culturally transmitted, and not necessarily stable. The author goes on to argue that an important aspect of technophysio evolution has been a change in the structure of consumption and in the division of discretionary time between work and leisure. The ongoing debate over whether or not the rapid advances in biotechnology will spare OECD nations' health systems from a financial crisis is addressed. Finally, the implications this argument has for forecasting China's future health care costs are discussed.     

Registered nurses: the impact of wages on labour force participation and hours worked – are wages an effective mechanism for addressing RN shortages with evidence from 1960 to 2008?

Registered nurses (RNs) are critical producers and coordinators of patient care in acute and non-acute settings (Needleman et al. 2011). The Affordable Care Act coupled with an ageing population, are increasing demand for health care and, in turn, RNs. Numbering 3 million, RNs comprise the largest professional occupation in health care. Therefore, the labour force participation and hours worked are of keen interest to stakeholders and policymakers. Rising demand may exacerbate nursing shortages and have important effects on costs. We estimate the impact of wages on participation and hours worked as a possible policy tool to increase nursing supply. In 2008, the RN wage had a positive and significant effect on participation and a small positive but only marginally significant effect on hours worked given participation. The latter elasticity for married females (single females) was 0.11 (0.33). Therefore, the elasticity of hours worked with respect to the nurse wage is and unlikely to have an important effect on the participation rates or hours worked of currently trained female RNs. Consequently, wage increases are unlikely to be an effective policy to increase the labour supply among the currently licensed RNs and will not relieve any short-term nursing shortage.     

Deregulation and privatization of Britain's local bus industry

In 1986,the British government deregulated the majority of the local bus industry, cut the amount of subsidy, and privatized many public bus companies. Unit costs have declined significantly, cross-subsidies have been reduced, and there has been innovation in operating practices. However, mergers have increased concentration, and demand has declined due to the turmoil of service changes and the loss of network integration. In London an alternative policy has been adopted whereby there is Demsetz competition for short-term monopoly rights. The paper argues that this regime will lead to greater benefits in the long run.     

The economics of standardized patient education materials with veteran patients

With an increasing number of veterans seeking care, it becomes imperative that the resources within the system are used efficiently and effectively and in a manner that maintains access, safety, and quality of care. Veterans who are able to manage their own care may utilize provider services less frequently, thereby increasing access for others who require more care. The objective of this quality improvement study was to determine the effectiveness of providing a standardized self-management textbook of health information with the intent that it would decrease demand on primary care providers' time for minor health care issues. This initial quality improvement study clearly demonstrated the potential of the return on investment and the subsequent potential for increased access for veteran patients, appropriate use of limited resources, and improved patient outcomes. It also clearly demonstrated the value of interaction with the veterans to educate them about their care and the increased satisfaction individualized attention to their needs creates. That finding alone has a greater value than just economics.     

Efficiency of health care delivery systems: effects of health insurance coverage

Health insurance expansions may increase the demand for care-creating incentives for health systems to increase input consumption. The possibility remains that added capacity and personnel will have little effect on health outcomes, decreasing the technical efficiency of health care delivery systems. We estimate that a 1 percentage point increase in health insurance coverage decreases the technical efficiency of health care delivery by 1.3 percentage points, translating into approximately 50 billion dollars in additional health expenditures. This finding uncovers a previously unexplored consequence of changes in health insurance on the supply side of health care markets suggesting one avenue through which health care costs growth may occur.