The role of medical schools in progressive health care

AIM: To analyse the predicted and observed role of medical schools in the progressive health care. DATA AND METHODS: The data derives from the financial database of the National Health Insurance Fund (NHIF) and covering the period 1998-2001. In this study the authors calculated the market share of the medical schools within the financing of the NHIF in the field of out- and in-patient care, renal dialysis, CT/MRI examinations, task financed services under special rules and fee for progressive (tertier level) care. The authors performed a detailed analysis concerning the Diagnosis Related Groups (DRG) of active inpatient care, where the market share of medical schools was calculated within the TOP-15 DRGs with highest and lowest point value, and within the TOP-15 most common and most infrequent DRGs. RESULTS: The market share of medical schools increased from 13.7% (1998) to 15.0% (2001). The increase was significant in the active and chronic in-patient care and in renal dialysis. The market share of medical schools from progressive fee decreased from 32.3% (1998) to 26.5% (2001). Within the active in-patient care the medical schools provide health care for 37.7% of the most difficult cases with highest DRG value and for 30.1% of the patients with rare diseases. The market share of the medical schools is much lower in cases with lowest DRG value (10.2%) and in most common cases (9.8%). CONCLUSION: The medical schools fulfilled their expected role in the progressive (tertier) care, answering the public and professional expectations.     

Competitive spillovers across non-profit and for-profit nursing homes

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.     

Factors affecting the entry of for-profit providers into a price regulated market for formal long-term care services: A case study from Japan

While the distinct behaviors of for-profit and non-profit providers in the healthcare market have been compared in the economic literature, their choices regarding market entry and exit have only recently been debated. Since 2000, when public Long-Term Care Insurance was introduced in Japan, for-profit providers have been able to provide formal long-term homecare services. The aim of this study is to determine which factors have affected market entry of for-profit providers under price regulation and in competition with existing non-profit providers. We used nation-wide panel data from 2002 to 2010, aggregated at the level of local public insurers (n = 1557), a basic area unit of service provision. The number of for-profit providers per elderly population in the area unit was regressed against factors related to local demand and service costs using first-difference linear regression, a fixed effects model, and Tobit regression for robustness checking. Results showed that demand (the number of eligible care recipients) and cost factors (population density and minimum wage) significantly influenced for-profit providers' choice of market entry. These findings indicate that for-profit providers will strategically choose a local market for maximizing profit. We believe that price regulation should be redesigned to incorporate quality of care and market conditions, regardless of the profit status of the providers, to ensure equal access to efficient delivery of long-term care across all regions.     

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania

Little is known about health system equity in Tanzania, whether in terms of distribution of the health care financing burden or distribution of health care benefits. This study undertook a combined analysis of both financing and benefit incidence to explore the distribution of health care benefits and financing burden across socio-economic groups. A system-wide analysis of benefits was undertaken, including benefits from all providers irrespective of ownership. The analysis used the household budget survey (HBS) from 2001, the most recent nationally representative survey data publicly available at the time, to analyse the distribution of health care payments through user fees, health insurance contributions [from the National Health Insurance Fund (NHIF) for the formal sector and the Community Health Fund (CHF), for the rural informal sector] and taxation. Due to lack of information on NHIF and CHF contributions in the HBS, a primary survey was administered to estimate CHF enrollment and contributions; assumptions were used to estimate NHIF contributions within the HBS. Data from the same household survey, administered to 2224 households in seven districts/councils, was used to analyse the distribution of health care benefits across socio-economic groups. The health financing system was mildly progressive overall, with income taxes and NHIF contributions being the most progressive financing sources. Out-of-pocket payments and contributions to the CHF were regressive. The health benefit distribution was fairly even but the poorest received a lower share of benefits relative to their share of need for health care. Public primary care facility use was pro-poor, whereas higher level and higher cost facility use was generally pro-rich. We conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidization and greater reliance on general taxation to finance health care for the poorest.     

For-profit status and industry evolution in health care markets: evidence from the dialysis industry

This paper examines why for-profit dialysis providers have displaced non-profit providers over the last 25 years. Using detailed data on individual markets’ evolutions, I find that for-profit facilities were quicker to enter growing markets and slower to exit declining ones than non-profit facilities. Moreover, for-profit providers’ presence in a market had a larger impact on the exit and entry behavior of competitors. These results suggest that for-profit dialysis providers have an advantage in static competition relative to non-profit providers, and that this—rather than lower entry costs—explains their increasing prominence. Additional empirical analyses indicate that for-profits’ advantage cannot solely be attributed to efficiencies related to membership in a large, multi-facility chain. This further suggests that managerial incentives have had an economically significant impact on long-run market structure in this industry.     

Public, private and voluntary residential mental health care: is there a cost difference?

OBJECTIVES: To determine how public (NHS or local government), private (for-profit) and voluntary (non-profit) providers of residential mental health care compare. Do they support different clienteles? And do their services cost different amounts? METHODS: Based on a cross-sectional survey of residential care facilities and their residents in eight English and Welsh localities, the characteristics and costs of care in the different sectors (NHS, local government, private, voluntary) were compared. Variations in cost were examined in relation to residents' characteristics using multiple regression analyses, which also allowed standardisation of results before making inter-sectoral comparisons. RESULTS: Private and voluntary providers of residential care support different clienteles from the public sector. The patterns of inter-sectoral cost differences vary between London and non-London localities. In London, voluntary sector facilities may be more cost-efficient than the other sectors, but local government/private sector comparisons show no consistent difference. Outside London, the results suggest clear cost advantages for the private and voluntary sectors over the local government sector. CONCLUSIONS: Private and voluntary providers may have some economic advantages over their public counterparts. However, outcomes for residents were not studied, leaving unanswered the question of comparative cost-effectiveness.     

Patient satisfaction in Bangkok: the impact of hospital ownership and patient payment status.

INTRODUCTION: Patient satisfaction with care received is an important dimension of evaluation that is examined only rarely in developing countries. Evidence about how satisfaction differs according to type of provider or patient payment status is extremely limited. OBJECTIVE: To (i) compare patient perceptions of quality of inpatient and outpatient care in hospitals of different ownership and (ii) explore how patient payment status affected patient perception of quality. METHODS: Inpatient and outpatient satisfaction surveys were implemented in nine purposively selected hospitals: three public, three private for-profit and three private non-profit. RESULTS: Clear and significant differences emerged in patient satisfaction between groups of hospitals with different ownership. Non-profit hospitals were most highly rated for both inpatient and outpatient care. For inpatient care public hospitals had higher levels of satisfaction amongst clientele than private for-profit hospitals. For example 76% of inpatients at public hospitals said they would recommend the facility to others compared with 59% of inpatients at private for-profit hospitals. This pattern was reversed for outpatient care, where public hospitals received lower ratings than private for-profit ones. Patients under the Social Security Scheme, who are paid for on a capitation basis, consistently gave lower ratings to certain aspects of outpatient care than other patients. For inpatient care, patterns by payment status were inconsistent and insignificant. CONCLUSIONS: The survey confirms, to some extent, the stereotypes about quality of care in hospitals of different ownership. The results on payment status are intriguing but warrant further research.     

The comparative performance of for-profit and nonprofit home health care services in the US

OBJECTIVE: To determine, by way of an exhaustive, systematic, and comprehensive review and summary of all scientific published studies, whether or not there are any performance differences between private for-profit and private nonprofit home health care providers. The second objective is to discover the proportion of all research on this topic that is devoted to home health care services compared to all other health services providers. DATA SOURCES: Computerized bibliographic searches of relevant databases and published indexes and abstracts were undertaken. They included Medline (Ovid and Pubmed versions), Web of Science (Social Sciences Citation Index and Science Citation Index), ABI/Inform, and Sociological Abstracts. Follow-up searches of reference lists in each article obtained from the computerized search were then completed. STUDY DESIGN: This systematic review retained for analysis all published studies that compared the performance of for-profit and nonprofit health care providers on access, quality, cost/efficiency, and/or amount of charity care, based on data collected after 1980. As a quality control measure only studies published in peer reviewed journals were included. Studies were coded according to the article's stated conclusions: for-profit superiority, nonprofit superiority, or no difference/mixed results. PRINCIPAL FINDINGS: The comparative performance of for-profit and nonprofit home health service organizations is one of the most understudied areas of health care provider services in the US today. Only 6 of the over 1030 comparisons of the two concerned home health care. No data on this topic have been collected since 1991, and no articles about it have been published in a peer-reviewed journal since 1995. CONCLUSION: Research on the relative performance of for-profit and nonprofit home health care services is a research priority urgently in need of attention.     

"Make or buy" decisions in the production of health care goods and services: new insights from institutional economics and organizational theory

A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with expensive, complex and concentrated production forms such as hospital care require a stronger regulatory environment and skilled contracting mechanisms before governments can rely on obtaining these services from the private sector. Subsidiary activities within the production process can often be unbundled and outsourced.     

Third sector primary care for vulnerable populations.

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based M?ori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.     

Managing competition in the countryside: Non-profit and for-profit perceptions of long-term care in rural Ontario

This paper contributes to the current debates surrounding private delivery of health care services by addressing the distinctive challenges, constraints and opportunities facing for-profit and non-profit providers of long-term care in rural and small town settings. It focuses on the empirical case of Ontario, Canada where extensive restructuring of long-term care, under the rubric of managed competition, has been underway since the mid-1990s. In-depth interviews with 72 representatives from local governments, public health institutions and authorities, for-profit and non-profit organisations, and community groups during July 2003 to December 2003 form the platform for a qualitative analysis of the implications of managed competition as it relates to the provision of long-term care in the countryside. The results suggest that the introduction and implementation of managed competition has accentuated the problems of service provision in rural communities, and that the long-standing issues of caregiving in rural situations transcend the differences, perceived or otherwise, between for-profit and non-profit provision. Understanding the implications of market-oriented long-term care restructuring initiatives for providers, and their clients, in rural situations requires a re-focussing of research beyond the for- versus non-profit dichotomy.     

Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand

This paper contributes to analysing and understanding the demand for (social) health insurance of informal sector workers in Kenya by assessing their perceptions and knowledge of and concerns regarding health insurance and the Kenyan National Hospital Insurance Fund (NHIF). It serves to explore how informal sector workers could be integrated into the NHIF. To collect data, focus group discussions were held with organized groups of informal sector workers of different types across the country, backed up by a self-administered questionnaire completed by heads of NHIF area branch offices. It was found that the most critical barrier to NHIF enrollment is the lack of knowledge of informal sector workers about the NHIF, its enrollment option and procedures for informal sector workers. Inability to pay is a critical factor for some, but people were, in principle, interested in health insurance, and thus willing to pay for it. In sum, the mix of demand-side determinants for enrolling in the NHIF is not as complex as expected. This is good news, as these demand-side determinants can be addressed with a well-designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates.     

Surveillance of AIDS and HIV infection: opportunities and challenges

From 1980 to 1984 Americans with no health insurance increased from 13.9% to 17.1% of the non-elderly population. Non-elderly persons covered by Medicaid declined from 6.2% to 5.6%. Previous studies of the share of the burden of uncompensated care borne by various provider groups present opposing findings. The National Hospital Discharge survey data presented here demonstrate that for-profit hospitals serve significantly lower percentages of uninsured discharges than secular or church-affiliated non-profit hospitals and public hospitals. The same pattern of differentials is observed with respect to Medicaid. On the whole the results of the survey tend to support the argument that private non-profit hospitals do indeed render greater public services in treating indigent patients than do for-profit hospitals. It must also be emphasized, however, that the results show all private hospitals falling somewhat short of the standard set by public hospitals in treating indigents. Thus, the continued shrinkage of the public hospital sector has serious policy implications.     

Public health care providers and market competition: the case of Finnish occupational health services

Background  

As reforms in publicly funded health systems rely heavily on competition, it is important to know if and how public providers react to competition. In many European countries, it is empirically difficult to study public providers in different markets, but in Finnish occupational health services, both public and private for-profit and non-profit providers co-exist. We studied possible differences in public providers’ performance (price, intensity of services, service mix—curative medical services/prevention, productivity and revenues) according to the competitiveness of the market.     

Profit and Non-Profit Home Health Care Agency Outcomes

The home health care industry, traditionally an industry of non-profit organizations, has increasingly become, as has the rest of the health care industry, invaded by for-profit organizations. The impetus for this invasion was the Omnibus Reconciliation Act (OBRA) of 1980 which encouraged previously restricted for-profit organizations to participate in the Medicare and Medicaid home health care program. Following enactment of OBRA, the number of for-profit organizations grew rapidly and the advantages and disadvantages of their presence in the market has been widely debated. The purpose of this study was to describe differences in behaviors and industry outcomes generated by non-profit and for-profit organizations in Massachusetts. Data for the study was from the Massachusetts State Department of Public Hcalth's Annual Reports of Home Health Agencies. Results suggest that while profit and non-profit agencies behave similarly in many areas, there are areas of difference, with significant differences found in the amount of service delivered and the rates charged.     

Profit and non-profit home health care agency outcomes: a study of one state's experience

The home health care industry, traditionally an industry of non-profit organizations, has increasingly become, as has the rest of the health care industry, invaded by for-profit organizations. The impetus for this invasion was the Omnibus Reconciliation Act (OBRA) of 1980 which encouraged previously restricted for-profit organizations to participate in the Medicare and Medicaid home health care program. Following enactment of OBRA, the number of for-profit organizations grew rapidly and the advantages and disadvantages of their presence in the market has been widely debated. The purpose of this study was to describe differences in behaviors and industry outcomes generated by non-profit and for-profit organizations in Massachusetts. Data for the study was from the Massachusetts State Department of Public Health's Annual Reports of Home Health Agencies. Results suggest that while profit and non-profit agencies behave similarly in many areas, there are areas of difference, with significant differences found in the amount of service delivered and the rates charged.     

Profits in medicine: a context and an accounting.

The U.S. health care industry is composed of a dynamic mixture of profit and non-profit entities. These sectors sometimes compete in the same activities and may have virtual monopolies over other activities. Estimates of the relative and absolute sizes and growth trends of the profit and non-profit sectors are developed in this article. These estimates show that approximately 39 percent of total health care expenditures in the U.S. in 1975 went to for-profit institutions, generating $3.3 billion in profit. This represented 7 percent of for-profit and 2.8 percent of total expenditures. Some for-profit subsectors grew more rapidly and others less rapidly than total health care expenditures. As a whole, the for-profit sector grew faster than the non-profit sector before and after Medicare and Medicaid were introduced as well as during the period when price controls were in effect. The relative growth of the for-profit sector was greatest right after the introduction of Medicare and Medicaid. The true significance of profit lies not in numbers, but in the effects that the drive for profit have on the nature and quality of health and health care. This is discussed in the final section.     

Hospital ownership and efficiency: a review of studies with particular focus on Germany

The German hospital market has been subject over the past two decades to a variety of healthcare reforms. Particularly the introduction of diagnosis-related groups (DRGs) in 2004 aimed to increase efficiency of hospitals. The objective of the paper is to review recent studies comparing the efficiency of German public, private non-profit and private for-profit hospitals. The results of the studies are quite mixed. However, in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., private non-profit and private for-profit) is not necessarily associated with higher efficiency compared to public ownership. This may be a surprising result to many policy makers as private for-profit hospitals are often perceived the most efficient ownership type by the public.     

Health care plans: interfaces between the public and private system in the dental sector

The present work presents a brief history of health plans in Brazil examining the interface between the public and the private sector. The evolution and regulation of the supplementary care system is analyzed, the different care modalities are defined and the main differences between health plans and dental care insurance are pointed out. The coverage provided by the supplementary care system and its relationship with the public health system is shown on the basis of current data. On the other hand, the study focuses on the care services, health plans and the labor market in the sector correlating, also on the basis of current data, the challenges and new opportunities of the supplementary care market, mainly in the dental sector. Although the dental sector is living an extraordinary moment within the private health care system and given that ANS data are pointing to a growth of this sector of 210% over last the 7 years, the service coverage of the supplementary care sector mainly directed to medical and inpatient care does not meet the real demand for integrated health care.