Changes in hospital efficiency and size: An integrated propensity score matching with data envelopment analysis

Turkey has made huge investments in city hospitals. The distinguishing feature of these hospitals is that they are physically large. Although many studies have investigated the efficiency of public hospitals, there are a few studies on the effect of hospital size on efficiency. This study examines the effect of hospital size on changes in public hospital efficiencies. The analysis is made up of three steps. First, using a bootstrap data envelopment analysis (DEA), the pure efficiency scores of each hospital were calculated. Second, propensity score matching (PSM) was used to ensure that any differences could be attributed to a particular class of hospital size, and not be due to differences in sample characteristics between the intervention and control groups. To highlight a potential time difference between small and large hospitals, the efficiencies of hospitals were examined from 2014 to 2017. Third, the Mann–Whitney U test was used to conduct a robustness check of the DEA and PSM results. Fourth, logistic regression was used on balanced data to examine the determinants of the efficiency of public hospitals. There are remarkable differences in the results obtained before and after matching the groups based on the bed-occupancy rate. Additionally, urban location is a key predictor of efficient and inefficient hospitals. This study also highlights that integrating DEA and PSM is a useful strategy in accurately identifying predictors of efficiencies of hospitals by creating balanced groups. Health policymakers should consider the efficiency advantages of high workload and service burden in the planning of public hospitals.     

The impacts of hospital alliance membership,alliance size,and repealing certificate of need regulation,on the cost efficiency of non‐profit hospitals

This paper investigates how alliance membership, size of the alliance, membership in multiple organizations, repealing certificate of need (CON) regulation for acute care facilities, and other factors, impacts hospital cost efficiency. Using a 1996–1999 panel of 144 urban US Midwestern hospitals, empirical results show that repealing state CON programs, signing more HMO and PPO contracts, and membership in only an alliance, helped to enhance cost efficiency. Membership in an additional organization (network, system) did not help enhance hospital cost efficiency. Membership in a larger size alliance (more hospitals in the alliance) contributed to an improvement in cost efficiency. Copyright © 2010 John Wiley & Sons, Ltd.     

The scale of hospital production in different settings: one size does not fit all

This paper analyses the productive efficiency of 141 public hospitals from 1998 to 2004 in two Canadian provinces; one a small province with a few small cities and a generally more rural population and the other a large province that is more urban in nature, with a population who mainly live in large cities. The relative efficiencies of the hospitals, the changes in productivity during this time period, and the relationship between efficiency and the size or scale of the hospitals are investigated using data envelopment analysis. The models for the production of health care use case mix adjusted hospital discharges as the output, and nursing hours as inputs. We find clear differences between the two provinces. Making use of ‘own’ and ‘meta’ technical efficiency frontiers, we demonstrate that efficient units in the larger and more urban province are larger than non-efficient units in that province. However, efficient hospitals in the smaller and more rural province are smaller than non-efficient hospitals in that province. Overall, efficient hospitals in the larger more urban province are larger than efficient hospitals in the smaller more rural province. This has interesting policy implications—different hospitals may have different optimal sizes, or different efficient modes of operation, depending on location, the population they serve, and the policies their respective provincial governments wish to implement. In addition, there are lessons to be learned by comparing the hospitals across the two provinces, since the inefficient hospitals in the small rural province predominantly use hospitals from the large urban province as benchmarks, such that substantially larger improvement potential can be identified by inter-provincial rather than intra-provincial benchmarking analysis.     

Focus as emphasis: Conceptual and performance implications for hospitals

Focus in hospitals has been heralded as the next frontier in improving its efficiency and efficacy (Herzlinger, 2004). However, there is scarce empirical work examining its effects in this setting. Focus in hospitals can take several different forms, ranging from standalone specialty centers to a hospital that chooses to emphasize in some operational way a particular specialty while still offering a full range of services. Although standalone facilities can be found in many locations, the vast majority of hospitals must follow the latter route to achieve focus. Current conceptualizations and measures of focus struggle to capture this construct in a way that does not assume a narrowing of range of offerings. In contrast to the traditional view of focus as narrowing, in this paper, we address the perspective of focus as emphasis. We select cardiology as the specialty and use secondary data for more than 264,000 patients in New York State to examine the relationship between focus as emphasis and hospital cost performance. Our results support the notion that such focus is associated with lower costs. Moreover, our results also show that focus in hospitals can be operationalized as a disproportionate emphasis on one line of service, without necessarily narrowing the overall range of services provided.     

Hospital efficiency and equity in health care delivery: A study based in China

Hospital efficiency and equity in health care delivery are two enduring research topics. Yet little research has been done to examine the relationship between them. This paper studies the impact of hospital efficiency on equity in health care delivery based on a proprietary dataset of hospital characteristics and 630,000 inpatient records from 149 public hospitals in a representative Chinese city. To measure the hospitals' efficiencies, this study takes the hospitals' operational features and case-mix indexes into account, and computes the efficiency levels using data envelopment analysis with bootstrapping. Through regressions that control for a variety of the patients’ personal characteristics (e.g., age, disease, residence, hospital visit frequency), this study shows that the gap between hospitalization expenses of urban and rural inpatients in more efficient hospitals is smaller than those in less efficient hospitals. Thus efficiency enhances equity in expenditure between urban and rural patients. But the dwindling urban-rural gap in expenditure is achieved by raising the spending of rural patients, thereby undermining their access to health care. This pattern is more conspicuous in large and sophisticated high-tier hospitals. Further analysis shows that hospital efficiency impacts equity of health care delivery by inducing different lengths of stay and uncovered parts of total expenditure for urban and rural groups. The findings imply that an efficiency-oriented health care policy may lead to social benefit loss.     

Evaluation of efficiency in Colombian hospitals: An analysis for the post-reform period

In this study we analyze the performance of 602 level 1 Colombian hospitals for the period 2009–2013. The analysis is carried out from both static and temporal perspectives in order to evaluate the evolution of total factor productivity (change in hospital performance) and its components throughout the period. The study also explores a question relevant not only to the Colombian health system, but to many others around the world, of whether primary care centers excessively refer patients to high-level hospitals, thereby negatively affecting the quality, efficiency, and effectiveness of all healthcare service provision. The results demonstrated that adjusted production (service provision) and levels of quality and referrals to higher-level hospitals could be improved, on average, by 44%. This increase in health service provision levels and their quality can be achieved by reducing personnel expenditure (by an average of 22%), expenditure on medicines (by 20%), and purchasing expenses (by 11%). The temporal analysis shows that total factor productivity (hospital performance change) worsened by 1% during the period, mainly due to the technological backlash experienced despite a slightly positive evolution in efficiency.     

Technical efficiency,specialization and ownership form: evidences from a pooling of Italian hospitals

We evaluate how the productive structure and level of specialization of a hospital affect technical efficiency by analyzing a six-year panel database (2000/2005) drawn from hospital discharge records and Ministry of Health data. We adopt a distance function approach, while measuring the technical efficiency level with stochastic frontier techniques. After controlling for environmental variables and hospital case-mix, inefficiency is negatively associated with specialization and positively associated with capitalization. Capitalization is typical of private structures which, on average, use resources less efficiently with respect to public and not-for-profit hospitals. Finally, by looking at scale elasticities, we find some evidence of unexploited economies of scale, leaving room for centralization.     

Effect of armed conflicts on humanitarian operations: Total factor productivity and efficiency of rural hospitals

We study an important but widely neglected topic in humanitarian operations: armed conflicts. Specifically, this paper empirically analyzes the effect of armed conflicts on the operational performance of first-layer response organizations. Using as a case study the Colombian conflict we investigate the effect of conflict on public rural hospitals' (i) total factor productivity, (ii) efficiency and (iii) efficiency variability. The panel data set (2007–2011) used in this study includes information at the hospital level for 163 hospitals and qualitative data collected from interviews with medical staff from the Colombian Ministry of Health and hospitals in different conflict zones. Our results indicate that armed conflict has a positive effect on total factor productivity, while it has a negative impact on hospital efficiency, and interestingly that efficiency and total factor productivity both increase in post conflict. Finally, the results show that efficiency variability is higher in peace and post-conflict hospitals and lower in medium and severe-conflict hospitals. These results have operations management implications and opportunities for future research related to sourcing decisions, supply chain and workforce flexibility, behavioral impacts on the workforce, and humanitarian response to conflicts.     

Relating focus to quality and cost in a healthcare setting

Focus in healthcare has been heralded as the next frontier in improving its efficiency and efficacy (Herzlinger 2004). Focus takes several different forms, ranging from standalone specialty centers to a hospital that places a strategic emphasis on a clinical area. We adopt this latter perspective and define focus as a disproportionate emphasis on a particular clinical area in a hospital. We use secondary data from hospitals providing cardiology care in New York State to examine the relationship between focus and performance. We develop two measures of focus. Proportional focus is defined to be the proportion of cases treated in a particular clinical specialty. Expertise focus is defined to be specific evidence that a hospital has taken action to build expertise in treating diseases in that specialty. We operationalize hospital performance along cost and quality dimensions, and we use hierarchical regression to examine the impact of focus on performance. Our results indicate that proportional focus, but not expertise focus, is associated with better cost performance. Quality performance, on the other hand, was associated only with the interaction between proportional focus and expertise focus, which means that only hospitals exhibiting higher levels of both proportional and expertise focus achieve better quality performance. These findings support the notion that not only is focus important in healthcare, but also that researchers and practitioners need to recognize that relationships are contingent on the performance and focus measures used and thus, findings may not be generalizable from one metric to another.     

Are hospitals producing quality care efficiently? An analysis using Dynamic Network Data Envelopment Analysis (DEA)

This paper examines efficiency of producing quality in hospitals between 2009 and 2013 using Dynamic Network Data Envelopment Analysis (DEA) and the hospital characteristics that contribute to this efficiency. Dynamic Network DEA was used to compute efficiency scores for hospital sub-divisions i.e. medical/surgical care (patient visits, surgeries and discharges) and quality. Pearson's correlation test was performed to assess if there are trade-offs or synergies between the efficiency of producing quality and efficiency of producing medical/surgical care. Multinomial logistic regression was performed to determine hospital and market characteristics that contribute to efficiency in production of quality outputs. Efficiency of quality production improved significantly between 2009 and 2013 with no trade-off between efficiency of producing quality outputs and efficiency of producing medical care. Urban and teaching hospitals were less likely to improve efficiency of quality production.     

Examining the impact of information technology and patient flow on healthcare performance: A Theory of Swift and Even Flow (TSEF) perspective

The impact of information technologies on manufacturing operations and performance is well established. However, scant research has been devoted to examining information technology (IT) investment among hospitals and how it influences patient care and financial performance. Using the lens of the Theory of Swift Even Flow (TSEF), we present an operations management-based perspective on the effect of IT in streamlining hospital operations. Specifically, we examined the role of IT on patient flow and its consequences for improved hospital efficiency and performance.     

浅谈电子病历标准化

电子病历是数字化的病人医疗健康记录,电子病历标准化是医院信息化、网络化发展的趋势。文章对电子病历的意义、标准化发展现状和存在的问题进行了阐述。     

Efficiency of U.S. hospitals between 2001 and 2011

This study focuses on finding the trend of efficiency in the healthcare industry in recent years. We applied stochastic frontier analysis and data envelopment analysis methods to capture the efficiency of 1,471 hospitals and found a sign of the Baumol effect, which is detected by the decreasing trend of hospital efficiency with increasing trend of labor costs. Furthermore, we compared the results of both approaches (stochastic frontier and data envelope analyses) in capturing efficiency scores and suggest the U‐shaped curve of the size effect may indicate the practice of “cream skimming” by some small hospitals.     

Regional variations in hospital occupancy rates

This paper analyzes theoretically and empirically SMSA differences in occupancy rates in short-term general hospitals. Because of the randomness of shortrun demands for admission to hospitals, occupancy rates are greater, the greater the admission rate, the larger the population, and the fewer the hospitals in the SMSA. Occupancy rates are higher where a greater proportion of the population is black and where the winters are colder, both due to longer hospital stays. More beds per capita lowers the occupancy rate. The efficiency of bed use could be increased by greater coordination among hospitals.     

The Role of Overbilling in Hospitals’ Earnings Management Decisions

Abstract

This paper examines the role of overbilling in hospitals’ earnings management choices. Overbilling by hospitals is a form of revenue manipulation that involves misclassifying a patient into a diagnosis-related group that yields higher reimbursement. As overbilling allows hospitals to increase revenues without altering operations, affecting costs, or having to reverse such behavior in the future, I propose and find that overbilling reduces hospitals’ use of managing accruals or cutting discretionary expenditures. Next, I find that hospital managers prefer overbilling to managing accruals (cutting discretionary expenditures) when cutting discretionary expenditures (managing accruals) is constrained, and vice versa. Collectively, my findings suggest that overbilling is an important alternative manipulation tool in hospitals.     

Accidental,unprepared, and unsupported: clinical nurses becoming managers

To what extent have hospitals developed their skilled clinicians to perform the administrative and human resources (HR) manager role of the ward manager? We consider this research question through an analysis of an acute hospital called ‘The Hospital’ where the executive team is aiming to adopt a form of high-performance work system (HPWS). We focus primarily on explanations in terms of conditions, rather than the personalities of individual managers, which are most powerful in shaping their behaviour. There has long been a failure of hospitals (and other employing organisations) to develop fully the skills required by employees before they become line managers. Line managers are a critical link in the high-performance chain and this study illustrates that, despite their rhetoric, hospitals may still have much potential for implementing schemes to develop nurses further to prepare them for line-manager positions and to support them after they move into such roles. We infer from this study that such hospitals may not yet have completed the journey to having HPWS. Hence, there is still much scope for such hospitals to progress and enjoy the benefits that proponents claim for HPWS.     

Technical and organisational aspects in enterprise resource planning systems implementation: lessons from a Spanish public hospital

Public resources should always be managed efficiently, more so in times of crisis. Due to the specific characteristics of the healthcare sector, there is a need for special attention, especially in regards to hospitals. Administrators need useful tools to be able to efficiently manage available resources, such as enterprise resource planning (ERP) systems. Therefore, an analysis of the effects of their implementation and use in hospitals is valuable. This study has two purposes. One is to analyse the role ERP systems play in aiding the integration of hospital data, with focus on user satisfaction as well as possible resistance to change. The other purpose is to analyse the effects of implanting and using ERP systems in the hospital environment and identifying how certain variables influence the process, especially the existence of different organisational cultures. Results indicate that clinical information has become notably more integrated, despite the lack of flow in the economic–financial area. The heterogeneous nature of the different groups, clinical (Medical, Nursing) and non-clinical (Economic–Financial, Accounting), had a negative influence on the implementation process, and limited the integration of information as well as the system's performance.     

Technical efficiency and the competitive behavior of hospitals

This paper examines whether the competitive behavior of hospitals influences the extent to which their productive efficiency deviates from best-practice standards. An index of technical inefficiency is constructed by means of Data Envelopment Analysis (DEA) for 189 acute-care hospitals in the State of Florida in 1989. A regression model is then specified that estimates the impact of competitive dynamics in local hospital markets over the period 1982–1988 on these 1989 DEA efficiency scores, controlling for a set uf internal and external constraints on managerial decision making. Among other things, the empirical analysis shows that these ratings are systematically accounted for by both the nature and vigor of hospital competition, with price leaders in highly competitive markets in particular shown to be more efficient. The public policy implications of these findings are discussed.     

浅析医院无线网络存在的安全问题及解决对策

构建无线网络是促进医院信息化发展的重要举措。基于5G技术的发展,进一步优化无线网络布局是优化医院资源共享成果、实现医院数字化建设的重要保障。然而医院无线网络在使用的过程中存在安全问题。因此,论文立足于医院无线网络安全的重要性,提出医院无线网络存在的安全问题,最后提出相应的解决对策,以期提升无线网络的运行效率。     

Impact of conversion to Critical Access Hospital status on hospital efficiency

This study examines the impact of Critical Access Hospital (CAH) Program on hospital efficiency using a two-stage approach, where data envelopment analysis is used in the first stage to estimate cost, technical, and allocative efficiency scores of a sample of rural hospitals. Densities of efficiency scores of CAHs and prospectively paid rural hospitals are estimated and compared using a nonparametric kernel density estimator and a bootstrap-based test. In the second stage, efficiency scores are regressed on environmental variables using bootstrapped truncated regressions. Density analysis and results from bootstrapped truncated regressions show that CAHs are less cost and allocatively efficient compared to prospectively paid rural hospitals, without being less technically efficient. Relative to their pre-conversion selves, CAHs appear to be slightly less allocatively efficient, while they are slightly more technically efficient and no less cost efficient. Overall, our results suggest that the CAH Program may have decreased the allocative and cost efficiencies of those rural hospitals that converted to CAH status relative to prospectively paid rural hospitals, without significantly increasing their technical efficiency.