Competition policy for health care provision in Norway

Competition policy has played a very limited role for health care provision in Norway. The main reason is that Norway has a National Health Service (NHS) with extensive public provision and a wide set of sector-specific regulations that limit the scope for competition. However, the last two decades, several reforms have deregulated health care provision and opened up for provider competition along some dimensions. For specialised care, the government has introduced patient choice and (partly) activity (DRG) based funding, but also corporatised public hospitals and allowed for more private provision. For primary care, a reform changed the payment scheme to capitation and (a higher share of) fee-for-service, inducing almost all GPs on fixed salary contracts to become self-employed. While these reforms have the potential for generating competition in the Norwegian NHS, the empirical evidence is quite limited and the findings are mixed. We identify a set of possible caveats that may weaken the incentives for provider competition – such as the partial implementation of DRG pricing, the dual purchaser–provider role of regional health authorities, and the extensive consolidation of public hospitals – and argue that there is great scope for competition policy measures that could stimulate provider competition within the Norwegian NHS.     

Policies towards hospital and GP competition in five European countries

This study provides an overview of policies affecting competition amongst hospitals and GPs in five European countries: France, Germany, Netherlands, Norway and Portugal. Drawing on the policies and empirical evidence described in five case studies, we find both similarities and differences in the approaches adopted. Constraints on patients’ choices of provider have been relaxed but countries differ in the amount and type of information that is provided in the public domain. Hospitals are increasingly paid via fixed prices per patient to encourage them to compete on quality but prices are set in different ways across countries. They can be collectively negotiated, determined by the political process, negotiated between insurers and providers or centrally determined by provider costs. Competition amongst GPs varies across countries and is limited in some cases by shortages of providers or restrictions on entry. There are varied and innovative examples of selective contracting for patients with chronic conditions aimed at reducing fragmentation of care. Competition authorities do generally have jurisdiction over mergers of private hospitals but assessing the potential impact of mergers on quality remains a key challenge. Overall, this study highlights a rich diversity of approaches towards competition policy in healthcare.     

Introduction of freedom of choice for hospital outpatient care in Portugal: Implications and results of the 2016 reform

In Portugal, the National Health Service (NHS) assures universal access to medical treatment and care that is free at the point of delivery – except for relatively small user charges. Freedom of choice is limited and competition between the public and the private sectors is almost non-existent. In May 2016, the Ministry of Health introduced a new law that facilitates the referral of NHS users from primary healthcare units to outpatient consultations in NHS hospitals outside of the referral area. However, for inpatient care, patients are still bound to receive treatment within their referral area, which is determined by place of residence. The aim of the reform was to provide a timelier response to citizens' health needs and to increase efficiency. According to preliminary data from June 2016 to May 2017, 10.6% of all outpatient referrals from NHS primary health care units were made to an NHS hospital out of the referral area, with the highest proportion in the Lisbon (15.8%) region. In general, median waiting time for first outpatient consultation increased after the introduction of choice in the five specialties with the highest proportions of out-of-area referrals - but it reduced in two departments with the longest waiting times prior to the reform. The reform constitutes a major change to the relationship between NHS hospitals, with foreseeable consequences in hospital funding and the patients' perception of hospital quality.     

New labour and reform of the English NHS: user views and attitudes

Background The British National Health Service has undergone significant restructuring in recent years. In England this has taken a distinctive direction where the New Labour Government has embraced and intensified the influence of market principles towards its vision of a ‘modernized’ NHS. This has entailed the introduction of competition and incentives for providers of NHS care and the expansion of choice for patients. Objectives To explore how users of the NHS perceive and respond to the market reforms being implemented within the NHS. In addition, to examine the normative values held by NHS users in relation to welfare provision in the UK. Design and setting Qualitative interviews using a quota sample of 48 recent NHS users in South East England recruited from three local health economies. Results Some NHS users are exhibiting an ambivalent or anxious response to aspects of market reform such as patient choice, the use of targets and markets and the increasing presence of the private sector within the state healthcare sector. This has resulted in a sense that current reforms, are distracting or preventing NHS staff from delivering quality of care and fail to embody the relationships of care that are felt to sustain the NHS as a progressive public institution. Conclusion The best way of delivering such values for patients is perceived to involve empowering frontline staffs who are deemed to embody the same values as service users, thus problematizing the current assumptions of reform frameworks that market‐style incentives will necessarily gain public consent and support.     

利用竞争作为政策工具推进公立医院改革

市场配置医疗卫生资源不等同医疗市场私有化,其核心是引入竞争机制。医院竞争不仅存在于不同产权医院间,公立医院内部也可引入竞争。促进公立医院＂内部竞争＂的公共政策可充分发挥市场机制作用。由于医疗市场存在特殊性,竞争可能产生正面或负面影响。为取得预期效果,在促进竞争的同时,决策者需要科学设计政策环境,对公立医院竞争进行驾驭。加强管制、权利下放和信息发布三者并重将是现阶段利用竞争作为政策工具推进中国公立医院改革的关键。     

Market mechanisms and the management of health care. The UK model and experience

Examines recent reforms of the UK's National Health Service (NHS), and explores the pressures for change in the pursuit of an efficient NHS and the conflicts which this causes in an organization which was based on the aim of equity. In particular, addresses the "false revolutions" of managerial change introduced after the Griffiths Report (1983) and the accounting changes introduced in the wake of the Griffiths proposals. Evidence shows that these intended revolutions were limited in impact. The result of these failures has been the introduction of the "real revolution"--the internal market in health care. This is a radical change in both the NHS management arrangements and in service delivery, with the division of the NHS into purchasers (health authorities and GP fund holders) and providers (hospital and community services, whether provided by private, voluntary or state-owned facilities.     

Private medical services in the Italian public hospitals: the case for improving HRM

This study explores how Italian public hospitals can use private medical activities run by their employed physicians as a human resources management (HRM) tool. It is based on field research in two acute-care hospitals and a review of Italian literature and laws. The Italian National Health Service (NHS) allows employed physicians to run private, patient-funded activities ("private beds", surgical operations, hospital outpatient clinics, etc.). Basic regulation is set at the national level, but it can be greatly improved at the hospital level. Private activities, if poorly managed, can damage efficiency, equity, quality of care, and public trust in the NHS. On the other hand, hospitals can also use them as leverage to improve HRM, with special attention to three issues: (1) professional evaluation, development, and training; (2) compensation policies; (3) competition for, and retention of, professionals in short supply. The two case studies presented here show great differences between the two hospitals in terms of regulation and organizational solutions that have been adopted to deal with such activities. However, in both hospitals, private activities do not seem to benefit HRM. Private activities are not systematically considered in compensation policies. Moreover, private revenues are strongly concentrated in a few physicians. Hospitals use very little of the information provided by the private activities to improve knowledge management, career development, or training planning. Finally, hospitals do not use private activities management as a tool for competing in the labor market for health professionals who are in short supply.     

In defiance of the evidence: conservatives threaten to "reform" away England's National Health Service

David Cameron's Conservative-led coalition government is pressing ahead with a highly controversial bill to "reform" the National Health Service (NHS), abolishing existing management structures, opening up provider services to private competition from "any qualified provider", and establishing a competitive market system in place of planning. The proposals fragment the structures and run counter to the founding principles of the NHS, which in 1948 transcended the limitations of markets, delivering health care on the basis of maximum risk sharing and universal access to services, free at the point of use. Evidence shows markets are a costly and inadequate mechanism to deliver universal and comprehensive health care, and private providers will only bid for services where profits are guaranteed. Opposition to the proposals is strong among health professionals and informed opinion, and the bill has divided the coalition parties--but time is running out for those who reject the bill to mount a sustained and concerted resistance.     

Blurring the divide: Navigating the public/private landscape of fertility treatment in the UK

It is widely assumed that fertility patients in the UK are either privately funded or publicly funded through the National Health Service. This article challenges this distinction and demonstrates how the boundaries between public and private fertility treatment provision are increasingly blurred. It draws on interviews with 42 fertility patients and partners who had accessed in vitro fertilisation (IVF) through both the National Health Service and private providers, to demonstrate how participants were compelled to engage with a consumerist model of healthcare, even when they had access to publicly funded IVF cycles. Patients’ experiences of navigating fertility treatment revealed a hybrid public/private consumption landscape, which reflects the uneven process of privatisation across the fertility sector. This article demonstrates how healthcare privatisation has had profound consequences for all IVF patients.     

Upcoding in a National Health Service: the evidence from Portugal

For many years, evidence from the USA has pointed out to the existence of upcoding in management practices. Upcoding is defined as classifying patients in diagnosis‐related groups codes associated with larger payments. The incentive for upcoding is not restricted to private providers of care. Conceptually, any patient classification system that is used for payment purposes may be vulnerable to this sort of strategic behaviour by providers. We document here that upcoding occurs in a National Health Service where public hospitals have their payment (budget) tied to the classification of treatment episodes. Using diagnosis‐related groups data from Portugal, we found that the practice of upcoding has been used in the hospitals in a way leading to larger budgets (age of patients plays a key role). The effect is quantitatively small. Copyright © 2016 John Wiley & Sons, Ltd.     

Innovation and the English National Health Service: a qualitative study of the independent sector treatment centre programme

Over the past two decades, an international trend of exposing public health services to different forms of economic organisation has emerged. In the English National Health Service (NHS), care is currently provided through a quasi-market including 'diverse' providers from the private and third sector. The predominant scheme through which private sector companies have been awarded NHS contracts is the Independent Sector Treatment Centre (ISTC) programme. ISTCs were designed to produce innovative models of service delivery for elective care and stimulate innovation among incumbent NHS providers. This paper investigates these claims using qualitative data on the impact of an ISTC upon a local health economy (LHE) composed of NHS organisations in England. Using the case of elective orthopaedic surgery, we conducted semi-structured interviews with senior managers from incumbent NHS providers and an ISTC in 2009. We show that ISTCs exhibit a different relationship with frontline clinicians because they counteract the power of professional communities associated with the NHS. This has positive and negative consequences for innovation. ISTCs have introduced new routines unencumbered by the extant norms of professional communities, but they appear to represent weaker learning environments and do not reproduce cooperation across organisational boundaries to the same extent as incumbent NHS providers.     

Back to the market: yet more reform of the National Health Service.

Yet more reform of the National Health Service in England has been announced by the Department of Health. In opposition, the Labour Party criticized the creation of an "internal market" for health care by the Conservative government, but five years into the Blair administration, market incentives are to be reinvigorated and the private sector is to be embraced in ways not seen hitherto. New guidance signals the introduction of competitive contracting using cost-per-case currencies, more choice for patients in where they will receive hospital treatment, and the freeing of NHS care providers from the direct political control of ministers. It is intended that the monopolistic features of the NHS in England should give way to greater pluralism, in particular through contracts with privately owned health care organizations. However, there is little evidence to suggest that these policies will be effective, and a number of practical problems may obstruct implementation.     

Is having private health insurance associated with less support for public healthcare? Evidence from the Norwegian NHS

The purpose of this study was to investigate whether increased uptake of private health insurance (PHI) in a traditionally NHS type system is likely to affect support for the public healthcare system. Using the Norwegian healthcare system as our case, and building on a survey among 7500 citizens, with 2688 respondents, we employed multivariate analysis to uncover whether the preferences for public health services are associated with having PHI, controlling for key predictors such as socio-economic background, self-rated health and perceived health service quality, as well as age and gender. The basis for our analysis was the following two propositions related to the role of public healthcare, which the respondents were asked to score on a 5-point Likert scale (1 = “totally disagree”, 5 = “totally agree”): 1) “the responsibility of providing health services should mainly be public”, and 2) “the activity of private commercial actors should be limited”. The regression analyses showed that the willingness to increase the role of commercial private actors is positively associated with having a PHI. However, we found no relationship between holding a PHI and support for public provision of health services when other factors were controlled for.     

Health technology assessment in Portugal

The Portuguese healthcare system is often portrayed as a National Health Service (NHS) model, characterized by universal coverage, comprehensive benefits, nearly free services, national tax financing, and public ownership or control of the factors of production. However, in reality the system fails to accomplish these features in a complete way. There coexist a number of occupation-related health insurance schemes that were originally intended to be integrated into the NHS. In addition, in key areas the NHS does not provide the wide range of services it promises. The public sector has a predominant role in the provision of hospital stays and general practitioner consultations, but the private sector provides a major portion of specialist consultations, dental consultations, and diagnostic services. Major problems in the system led to health reforms in the 1990s. New reform proposals include some specific steps concerning health technology, including standards for medical equipment based on quality, geographic distribution, sustainability, and cost-effectiveness. A new National Plan of Health Equipment was completed in 1998, aimed at improving the distribution of equipment. Despite reforms, healthcare expenditures continue to rise. There is general agreement that gains in efficiency could be made. This situation is beginning to encourage interest in health technology assessment (HTA) in Portugal, although these activities are not yet very developed. Recently, legislation requiring presentation of economic evaluations for new pharmaceutical products was enacted. Present plans also call for the creation in the future of a national agency for HTA.     

Public versus private health care in a national health service

This paper studies the interaction between public and private health care provision in a National Health Service (NHS), with free public care and costly private care. The health authority decides whether or not to allow private provision and sets the public sector remuneration. The physicians allocate their time (effort) in the public and (if allowed) in the private sector based on the public wage income and the private sector profits. We show that allowing physician dual practice 'crowds out' public provision, and results in lower overall health care provision. While the health authority can mitigate this effect by offering a higher wage, we find that a ban on dual practice is more efficient if private sector competition is weak and public and private care are sufficiently close substitutes. On the other hand, if private sector competition is sufficiently tough, a mixed system, with physician dual practice, is always preferable to a pure NHS system.     

Ten years since the 2008 introduction of dental vouchers in the Portuguese NHS

Since the creation of the National Health Service (NHS) in Portugal, in 1979, dental care is neither provided nor funded by the NHS. Thus, most dental care is paid through out-of-pocket payments, either by patients themselves or through voluntary health insurance or health subsystems. In 2008 the government created the dental voucher targeting children, pregnant women, elderly who receive social benefits, and certain patient groups (HIV/AIDS patients and those who need early intervention due to oral cancer), to be used in private dentists who contracted with the programme. The reform was well received by the different stakeholders, especially dentists and beneficiaries, and the impact of the dental voucher in access and coverage of dental care in Portugal is positive: from May 2008 until December 2017, dental voucher reached 3.3 million NHS users in Portugal and dental care indicators have dramatically improved over the last ten years. Aiming to implement dental care provision within the NHS, the Ministry of Health has announced the foreseen integration of dentists in primary healthcare units, although the current budget constraints might hamper this possibility.     

The 2019 introduction of the new National Healthcare System in Cyprus

In 2019, Cyprus launched its new National Healthcare System (NHS) as one of the major structural reforms required by the bail-out agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika) which averted Cyprus bankruptcy in 2011. This paper presents the key features of the new NHS: A National Health Insurance Fund operated by the Health Insurance Organisation pays for services provided by a mix of public and private providers. A prerequisite for the establishment of this new quasi-market was the transfer of public hospitals from the Ministry of Health to the new State Health Services Organisation, thus establishing a purchaser-provider and regulator split. The first implementation phase started in June 2019 and introduced coverage of outpatient healthcare services for the entire population, providing access – with relatively small user charges – to family physicians, outpatient specialists, pharmaceuticals and laboratories. The second implementation phase began in June 2020 with the inclusion of hospital care, followed by the inclusion of specialty pharmaceuticals in September and was completed in December 2020. The reform is a vital achievement as it is a major step towards the goal of universal health coverage, reducing the excessive reliance on out-of-pocket payment and glaring inequities in access to care.     

Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom.

OBJECTIVES--To explore and describe the views on clinical audit of healthcare purchasers and providers, and in particular the interaction between them, and hence to help the future development of an appropriate interaction between purchasers and providers. DESIGN-- Semistructured interviews. SETTING--Four purchaser and provider pairings in the former Northern Region of the National Health Service (NHS) in England. SUBJECTS--Chief executives, contracts managers, quality and audit leaders, directors of public health, consultants, general practitioners, audit support staff, and practice managers (total 42). MAIN MEASURES--Attitudes on the present state and future development of clinical audit. RESULTS--Purchasers and providers shared common views on the purpose of clinical audit, but there were important differences in their views on the level and appropriateness of involvement of health care purchasers, integration with present NHS structures and processes (including contracting and the internal market), priority setting for clinical audit, the effects of clinical audit on service development and purchasing, change in behaviour, and the sharing of information on the outcomes of clinical audit. CONCLUSIONS--There are important differences in attitudes towards, and expectations of, clinical audit between health care purchasers and providers, at least in part due to the limited contact between them on audit to date. The nature of the relation and dialogue between purchasers and providers will be critical in determining whether clinical audit meets the differing aspirations of both groups, while achieving the ultimate goal of improving the quality of patient care.     

DIFFERENCES IN LENGTH OF STAY FOR HIP REPLACEMENT BETWEEN PUBLIC HOSPITALS,SPECIALISED TREATMENT CENTRES AND PRIVATE PROVIDERS: SELECTION OR EFFICIENCY?

We investigate differences in patients’ length of stay between National Health Service (NHS) public hospitals, specialised public treatment centres and private treatment centres that provide elective (non‐emergency) hip replacement to publicly funded patients. We find that the specialised public treatment centres and private treatment centres have, on average, respectively 18% and 40% shorter length of stay compared with NHS public hospitals, even after controlling for differences in age, gender, number and type of diagnoses, deprivation and regional variation. Therefore, we interpret such differences as because of efficiency as opposed to selection of less complex patients. Quantile regression suggests that the proportional differences between different provider types are larger at the higher conditional quantiles of length of stay. Copyright © 2012 John Wiley & Sons, Ltd.     

马来西亚卫生体系改革及对我国的启示

马来西亚卫生体系继承英国的国家卫生服务制度,有相对较为完整的公立卫生服务体系。但自20世纪70年代开始,马来西亚的私立医疗机构和私立医疗保险也得到了快速发展。本文主要描述了马来西亚卫生体系现状及主要私有化改革举措,认为马来西亚目前的医疗卫生机构主要存在完全公立医院、完全私立医院、公司化运作的公立医院和部分科室采取私有化运行的公立医院4种类型。文章进一步提出对我国规范发展私立医疗机构的启示：公民对卫生政策制订和实施应有更大发言权;合理界定公立和私立卫生机构;加强私立医疗卫生机构和私立医疗保险的管理;加快对私立医疗卫生机构管理的立法进程;建立公立和私立医疗卫生机构的合作机制。