Hospital competition under pay‐for‐performance: Quality,mortality, and readmissions

Health outcomes, such as mortality and readmission rates, are commonly used as indicators of hospital quality and as a basis to design pay‐for‐performance (P4P) incentive schemes. We propose a model of hospital behavior under P4P where patients differ in severity and can choose hospital based on quality. We assume that risk‐adjustment is not fully accounted for and that unobserved dimensions of severity remain. We show that the introduction of P4P which rewards lower mortality and/or readmission rates can weaken or strengthen hospitals' incentive to provide quality. Since patients with higher severity have a different probability of exercising patient choice when quality varies, this introduces a selection bias (patient composition effect) which in turn alters quality incentives. We also show that this composition effect increases with the degree of competition. Critically, readmission rates suffer from one additional source of selection bias through mortality rates since quality affects the distribution of survived patients. This implies that the scope for counterproductive effects of P4P is larger when financial rewards are linked to readmission rates rather than mortality rates.     

Hospital Competition and Quality with Regulated Prices*

We analyse the effect of competition on quality in hospital markets with regulated prices, considering the effect of both introducing competition (monopoly versus competition) and increasing competition through either lower transportation costs (increased substitutability) or a higher number of hospitals. With semi‐altruistic providers and a fairly general cost structure, we show that the relationship between competition and quality is generally ambiguous. In contrast to the received body of theoretical literature, this is consistent with, and potentially explains, the mixed empirical evidence.     

Horizontal mergers and product quality

We study the effects of a horizontal merger when firms compete on price and quality. In a Salop framework with three symmetric firms, several striking results appear. First, the merging firms reduce quality but possibly also price, whereas the outside firm increases both price and quality. As a result, the average price in the market increases, but also the average quality. Second, the outside firm benefits more than the merging firms from the merger, and the merger can be unprofitable for the merger partners, i.e., the “merger paradox” may appear. Third, the merger always reduces total consumer utility (though some consumers may benefit), but total welfare can increase due to endogenous quality cost savings. In a generalized framework with n firms, we identify two key factors for the merger effects: (i) the magnitude of marginal variable quality costs, which determines the nature of strategic interaction and (ii) the cross‐quality and cross‐price demand effects, which determines the intensity of price relative to quality competition. These findings have implications for antitrust policy in industries where quality is a key strategic variable for the firms.     

Hospital Competition with Soft Budgets

We study the incentives for quality provision and cost efficiency for hospitals with soft budgets, where the payer can cover deficits or confiscate surpluses. While a higher bailout probability reduces cost efficiency, the effect on quality is ambiguous. Profit confiscation reduces both quality and cost efficiency. First‐best is achieved by a strict no‐bailout and no‐profit‐confiscation policy when the regulated price is optimally set. However, for suboptimal prices, a more lenient bailout policy can be welfare‐improving. When we allow for heterogeneity in costs and qualities, we also show that a softer budget can raise quality for high‐cost patients.     

Quality competition with motivated providers and sluggish demand

We study incentives for quality provision in markets where providers are motivated (semi-altruistic); prices are regulated and firms are funded by a combination of block grants and unit prices; competition is based on quality, and demand adjusts sluggishly. Health or education are sectors in which the mentioned features are the rule. We show that the presence of motivated providers makes dynamic competition tougher, resulting in higher steady-state levels of quality in the closed-loop solution than in the benchmark open-loop solution, if the price is sufficiently high. However, this result is reversed if the price is sufficiently low (and below unit costs). Sufficiently low prices also imply that a reduction in demand sluggishness will lead to lower steady-state quality. Prices below unit costs will nevertheless be welfare optimal if the providers are sufficiently motivated.     

Competition in Regulated Markets with Sluggish Beliefs about Quality

We investigate the effect of competition on quality in regulated markets (e.g., health care, higher education, public utilities), using a Hotelling framework, in the presence of sluggish beliefs about quality. We take a differential‐game approach, and derive the open‐loop solution (providers choose the optimal quality investment plan based on demand at the initial period) and the feedback closed‐loop solution (providers observe demand in each period and choose quality in response to current demand). If variable costs are strictly convex, and the degree of cost complementarity between quality and output is not too strong, the steady‐state quality is higher under the open‐loop solution than under the feedback solution. In both solutions, quality and demand move in opposite directions over time on the equilibrium path to the steady‐state. While lower transportation costs or less sluggish beliefs lead to higher quality in both solutions, the quality response is weaker when players use feedback strategies.     

Performance Indicators for Quality with Costly Falsification

Performance indicators are increasingly used to regulate quality in health care and the public sector. We develop a model of contracting between a purchaser and a provider under the following assumptions: (a) providers have private information about their own ability and (b) they can engage in costly manipulation of quality measures. If the contract is separating, manipulation reduces the optimal quality effort but increases the quality targets. If the purchaser's benefit from quality is sufficiently concave, then pooling of high-ability types (or all types) turns out to be optimal. (Partial) pooling provides a rationale for quality ceilings and minimum quality standards.     

Hospital Mergers with Regulated Prices

We study the effects of a hospital merger in a spatial competition framework where semi‐altruistic hospitals choose quality and cost‐containment effort. Whereas a merger always leads to higher average cost efficiency, the effect on quality provision depends on the strategic nature of quality competition, which in turn depends on the degree of altruism and the effectiveness of cost‐containment effort. If qualities are strategic complements, then a merger leads to lower quality for all hospitals. If qualities are strategic substitutes, then a merger leads to higher quality for at least one hospital, and might also yield higher average quality provision and increased patient utility.     

Hospital cost sharing incentives: evidence from Iceland

Hospitals’ incentives to provide health care are influenced by the degree of cost sharing between the purchaser and the provider. In most OECD countries, governments remunerate hospitals according to the activity performed. Activity is usually measured through a diagnosis related groups (DRGs) system. This study estimates the degree of cost sharing of the NordDRG classification system (the DRG version of the Nordic countries) in Iceland during 2003–2005. We first apply ordinary least square (OLS) methods to estimate the degree of cost sharing by regressing the price for each individual patient against its cost. Second, we propose an instrumental-variable approach to address the potential endogeneity of costs. The OLS estimates suggest that the degree of cost sharing is in the range 0.16–0.17 (i.e. 1$ increase in cost is associated with an increase in reimbursement by 0.16–0.17$ increase in cost is associated with an increase in reimbursement by 0.16–0.17). The instrumental-variable approach provides some evidence of endogeneity, and suggests that cost sharing is overestimated by OLS. The instrumented estimates of cost sharing are 0.11, 0.13 and 0.14 in 2003, 2004 and 2005, respectively. Regardless of the method applied, most cost sharing is associated with the retrospective features of the classification system (such as the type of treatment provided).