Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Do private hospitals outperform public hospitals regarding efficiency,accessibility, and quality of care in the European Union? A literature review

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social‐economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for‐profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.     

Losing body weight for money: How provider‐side financial incentives cause weight loss in Swiss low‐birth‐weight newborns

Facing steadily rising health care costs, Switzerland introduced a system of diagnosis‐related groups (DRGs) for hospital payment in 2012 (SwissDRG) along with cost‐efficiency benchmarking between hospitals. On the one hand, SwissDRG puts hospitals at financial risk and strengthens incentives for efficiency by setting a fixed price per case. On the other hand, hospitals are incentivized to game the system and exploit adverse incentives. We investigate hospitals' behavioral response to financial incentives in Swiss neonatology. First, we provide strong evidence for manipulations of reported birth weight among low‐birth‐weight newborns. Using a difference‐in‐difference‐in‐difference design, we find that 14–27% of birth weights are manipulated around specific birth weight cutoffs. Second, we find evidence of an upward‐sloping supply curve of cheating, indicating that hospitals increasingly engage in fraudulent behavior as financial incentives increase. Our estimates indicate a supply‐sided price elasticity of cheating between 0.16 and 0.52.     

Supplementary private health insurance: The impact of physician financial incentives on medical practice

In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.     

Health Services Pricing in Turkey

Abstract

One of the most important and complex decisions that public services managers have to make is pricing. This is especially difficult within public health care because pricing decisions are influenced by a myriad of ideological, political, economic and professional arguments. In Turkey the majority of health care services are provided under public auspice; however, recent changes in governmental policy have led to increased competition among hospitals in both the public and private sector. Therefore, all institutions are being watched and remain open to government scrutiny and regulation. The aim of the study is to analyze how the private and governmental hospitals determine pricing or the actual cost of services in Turkey. Also, comparisons are made between health services expenditures and the Consumer Price Index with suggestions provided for public and private hospital managers in regard to the general cost of health services.     

南非公立医院改革的主要做法与特点

相对于私立医院占有五分之三的卫生支出为20%的人群提供服务,南非公立医院约使用五分之二的卫生支出,为南非80%的人群提供医疗卫生服务,但面临着资源不足和人力短缺的问题。为此,南非政府着重建立公平导向的卫生管理体制,加大政府财政投入,重点保障基层公立医院发展,探索公私合作,在优先保障弱势人群基本医疗服务的同时,动员可利用的所有医疗资源,着力保障居民公平地获得基本医疗卫生服务。改革的主要特点是建立以基本医疗卫生保健为基础的医疗管理体制,以更公平的方式分配医疗资源,建立公私合作机制,动员民营机构力量,优先保障居民对基本医疗卫生服务的可及性和公平性。这些经验对于同属于发展中国家的中国有良好启示。     

Public‐private partnerships in non‐profit hospitals: Case study of China

The gap between supply and demand for health care services is expanding rapidly in China. In order to resolve this problem, the government has implemented supply‐side reforms in the health care sector by inviting private capital to increase supply quantity and improve quality. However, health care institutions have high complexity and particular needs, while non‐profit hospitals have very strong public interests. This gives rise to complications in the implementation of public‐private partnerships (PPPs) for health care services. In this paper, the authors have selected one case each from three different models of non‐profit hospital PPP projects in the national PPP project database, operated by the Ministry of Finance, and compared how these projects were operated to identify the differences among them. A content analysis of the vital project documents is the primary analysis technique used for this comparison. Key issues investigated include reasons for model selection, requirements for private sectors and market competition level in different models, risk identification and sharing, design of payment mechanism, operation supervision, and performance appraisal of the project. Based on the comparison, some key lessons and recommendations are discussed to act as a useful reference for future non‐profit hospital PPP projects in China.     

Out of pocket health expenditures in Turkey following introduction of co-payments along with improved primary care services

In 2002, Turkey started to implement reforms in health care aiming to improve access and increase efficiency. Reforms increased health insurance coverage and resulted in higher number of outpatient and inpatient treatments at both public and private hospitals. Later, to change preference towards the use of secondary and tertiary care over primary care and rein in increasing health expenditures, a series of co-payments were instituted along with an extension of primary care services through a family-medicine system that provided free access to all. This work aims to measure the impact of these two simultaneous policy measures on out-of-pocket expenditures. We find that while contributory payments resulted in higher OOP health expenditures, especially for lower income households, the impact was small. We also observe that inability to consult a physician and to visit a hospital, especially for monetary reasons, was reduced after the policy change.     

Patient satisfaction with health services in Bangladesh

Concern over the quality of health care services in Bangladesh has led to loss of faith in public and private hospitals, low utilization of public health facilities, and increasing outflow of Bangladeshi patients to hospitals in neighbouring countries. Under the circumstances, assessment of the country's quality of health care service has become imperative, in which the patient's voice must begin to play a greater role. This study attempts to identify the determinants of patient satisfaction with public, private and foreign hospitals. A survey was conducted involving inpatients in public and private hospitals in Dhaka City and patients who have experienced hospital services in a foreign country. Their views were obtained through exit polls using probability and non-probability (for foreign hospital patients) sampling procedures. Regression models were derived to identify key factors influencing patient satisfaction in the different types of hospitals. Doctors' service orientation, a composite of 13 measures, is the most important factor explaining patient satisfaction. Policy implications are discussed.     

Does It Pay to Penalize Hospitals for Excess Readmissions? Intended and Unintended Consequences of Medicare's Hospital Readmissions Reductions Program

To incentivize hospitals to provide better quality care at a lower cost, the Affordable Care Act of 2010 included the Hospital Readmissions Reduction Program (HRRP), which reduces payments to hospitals with excess 30‐day readmissions for Medicare patients treated for certain conditions. We use triple difference estimation to identify the HRRP's effects in Virginia hospitals; this method estimates the difference in changes in readmission over time between patients targeted by the policy and a comparison group of patients and then compares those difference‐in‐differences estimates in patients treated at hospitals with readmission rates above the national average (i.e., those at risk for penalties) and patients treated at hospitals with readmission rates below or equal to the national average (those not at risk). We find that the HRRP significantly reduced readmission for Medicare patients treated for acute myocardial infarction (AMI). We find no evidence that hospitals delay readmissions, treat patients with greater intensity, or alter discharge status in response to the HRRP, nor do we find changes in the age, race/ethnicity, health status, and socioeconomic status of patients admitted for AMI. Future research on the specific mechanisms behind reduced AMI readmissions should focus on actions by healthcare providers once the patient has left the hospital. Copyright © 2016 John Wiley & Sons, Ltd.     

The impact of the financial crisis and austerity policies on the service quality of public hospitals in Greece

The influence of the financial crisis on the efficiency of Greek public hospitals has been widely debated. Despite this increasing interest in such research, the question of to what extent the recent reforms in the Greek National health care system were effective in establishing a health care structure and process that provide better results for patients has yet to be fully investigated. As a step in this direction, the paper focuses on patient's experience with public hospital care quality before and during the economic crisis. A questionnaire survey was carried out among 1872 patients discharged from 110 out of the total of 124 Greek public hospitals. Patients' perceptions were analysed using a structural equation modelling approach. The findings reveal that public hospital service quality is at a medium level (66.2 on a scale from 1 to 100) over 2007–2014, presenting a decreasing trend during the recession. Policies to address the crisis may have contributed to a reduction in hospital expenditures, but at the same time patients were increasingly dissatisfied with the technical care. Consequently, there is a need for reforms aimed at the achievement of productivity gains, responsibility, and transparency in the management of productive resources, by enabling health organisations to reduce their costs without a deterioration in the quality of care.     

Population characteristics of markets of safety-net and non-safety-net hospitals

Research Objectives To compare and contrast the markets of urban safety-net (USN) hospitals with the markets of other urban hospitals. Study Design To develop profiles of the actual inpatient markets of hospitals, we linked 1994 patient-level information from hospital discharge abstracts from nine states with 1990 data at the ZIP code level from the US Census Bureau. Each hospital's market was characterized by its racial and ethnic composition, median household income, poverty rate, and educational attainment. Measures of hospital competition were also calculated for each hospital. The analysis compared the market profiles of USN hospitals to those of other urban hospitals. We also compared the level of hospital competition and financial status of USN and other urban hospitals. Principal Findings The markets of USN hospitals had higher proportions of racial and ethnic minorities and non-English-speaking residents. Adults residing in markets of USN hospitals were less educated. Families living in markets of USN hospitals had lower incomes and were more likely to be living at or below the federal poverty level. USN hospitals and other urban hospitals faced similar levels of competition and had similar margins. However, USN hospitals were more dependent on Medicare disproportionate share payments and on state and local government subsidies to remain solvent. Conclusion USN hospitals disproportionately serve vulnerable minority and low-income communities that otherwise face financial and cultural barriers to health care. USN hospitals are dependent on the public subsidies they receive from federal, state, and local governments. Public policies and market pressures that affect the viability of USN hospitals place the access to care by vulnerable populations at risk. Public policy that jeopardizes public subsidies places in peril the financial health of these institutions. As Medicare and Medicaid managed care grow, USN hospitals may lose these patient revenues and public subsidies based on their Medicaid and Medicare patient volumes. The loss of these funds would hinder the ability of USN hospitals to finance uncompensated care for uninsured and underinsured patients. An earlier draft of this paper was presented as a poster at the 14th annual meeting of the Association for Health Services Research, Chicago, IL, June 15–17, 1997. Financial support for this research was provided by the Commonwealth Fund. The opinions expressed are solely those of the authors and do not necessarily reflect the positions of Georgetown University and the Commonwealth Fund.     

Health services pricing in Turkey

One of the most important and complex decisions that public services managers have to make is pricing. This is especially difficult within public health care because pricing decisions are influenced by a myriad of ideological, political, economic and professional arguments. In Turkey the majority of health care services are provided under public auspice; however, recent changes in governmental policy have led to increased competition among hospitals in both the public and private sector. Therefore, all institutions are being watched and remain open to government scrutiny and regulation. The aim of the study is to analyze how the private and governmental hospitals determine pricing or the actual cost of services in Turkey. Also, comparisons are made between health services expenditures and the Consumer Price Index with suggestions provided for public and private hospital managers in regard to the general cost of health services.     

The Impacts of China's Urban Employee Basic Medical Insurance on Healthcare Expenditures and Health Outcomes

At the end of 1998, China launched a government‐run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991–2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low‐income and middle‐income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self‐reported health status. Copyright © 2015 John Wiley & Sons, Ltd.     

The Impact of Accessibility on the Use of Specialist Health Care in Norway

The aim of this study is to explore to what extent the policy goal of allocating health care according to medical need is fulfilled in Norway. Hence, we are interested in studying the impact of a person's health relative to the impact of access to specialist care. We distinguish between services provided by public hospitals and services provided by private specialists financed by the National Insurance Scheme. While a person's self-assessed health plays a major role in the utilization of hospitals, we find no significant effect of this variable on the utilization of private specialists. The accessibility indices for specialist care have significant effects on the utilization of private specialists, but not on hospital visits and inpatient stays. The challenge to policy makers is to consider measures that bring the utilization of publicly funded private specialists in accordance with national health policy.     

Combined social and private health insurance versus catastrophic out of pocket payments for private hospital care in Greece

The high level of out of pocket (OOP) payments constitutes a major concern for Greece and several other European and OECD countries as a result of the significant down turning of their public health finances due to the 2008 financial crisis. The basic objective of this study is to provide empirical evidence on the effect of combining social health insurance (SHI) and private health insurance (PHI) on OOP payments. Further, this study examines the catastrophic impact of OOP payments on insured’s welfare using the incidence and intensity methodological approach of measuring catastrophic health care expenditures. Conducting a cross-sectional survey in Greece in 2013, we find that the combination of SHI–PHI has a strong negative influence on insured OOP payments for inpatient health care in private hospitals. Furthermore, our results indicate that SHI coverage is not sufficient by itself to manage with this issue. Moreover, we find that poor people present a greater tendency to incur catastrophic OOP expenditures for hospital health care in private providers. Drawing evidence from Greece, a country with huge fiscal problems that has suffered the consequences of the economic crisis more than any other, could be a starting point for policymakers to consider the perspective of SHI–PHI co-operation against OOP payments more seriously.     

Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand

The Thai government has implemented universal coverage of health insurance since October 2001. Universal access to antiretroviral (ARV) drugs has also been included since October 2003. These two policies have greatly increased the demand for health services and human resources for health, particularly among public health care providers. After the 1997 economic crisis, private health care providers, with the support of the government, embarked on new marketing strategies targeted at attracting foreign patients. Consequently, increasing numbers of foreign patients are visiting Thailand to seek medical care. In addition, the economic recovery since 2001 has greatly increased the demand for private health services among the Thai population. The increasing demand and much higher financial incentives from urban private providers have attracted health personnel, particularly medical doctors, from rural public health care facilities. Responding to this increasing demand and internal brain drain, in mid-2004 the Thai government approved the increased production of medical doctors by 10,678 in the following 15 years. Many additional financial incentives have also been applied. However, the immediate shortage of human resources needs to be addressed competently and urgently. Equity in health care access under this situation of competing demands from dual track policies is a challenge to policy makers and analysts. This paper summarizes the situation and trends as well as the responses by the Thai government. Both supply and demand side responses are described, and some solutions to restore equity in health care access are proposed.     

上海市三级公立医院特需服务发展的现状及趋势分析

目的:分析上海市三级公立医院特需服务发展的现状和趋势,为完善相关政策提供依据。方法:梳理公立医院特需服务管理的相关政策,并对2011—2013年上海市三级公立医院提供特需服务的机构数量、服务数量、价格、费用等进行定量分析。结果:上海市相关政策对特需服务规模具有明确要求,住院床位费、住院诊查费、护理费、门诊诊查费可由医院自主定价。2013年,上海市89.7%的三级公立医院开展了特需服务,特需服务数量变化较为平稳,但医院之间收费差别较大,2013年上海市三级公立医院特需服务总费用占全院总费用的6.2%,药占比低于全院平均水平。结论与建议:公立医院特需服务的存在具有历史必要性,短期内应加强其监管。公立医院应加强自身管理,规范提供特需服务。借鉴国际先进经验,形成公立医院多层次的医疗服务格局,并积极开展与社会办医疗机构的合作。     

Role of multi-purpose service programs providing residential aged care in rural Australia: a discussion paper

Objective: To determine if multi‐purpose service (MPS) Programs deliver improved residential aged care as opposed to traditional rural hospitals. Design: A variation on comparative–experimentalist: type 4. In this design 2 groups providing different service models of rural health services are compared. Setting: Six MPS Programs and three traditional hospitals in rural New South Wales. Subjects: Key stakeholders – area representatives, health service managers, MPS managers, doctors, staff, MPS or hospital committee members and consumer groups including residents. Main outcome measure: To analyse the ability of MPS Programs to deliver quality residential aged care as opposed to using traditional hospitals for such services. Results: Multi‐purpose service programs provided better residential environments and greater flexibility of service provision. There were few apparent differences between the two service models in regard to organisational culture and training. Conclusions: The findings of this evaluation suggest that in the provision of residential aged care in rural communities, MPS Programs demonstrated better standards of care than traditional hospital based services. What is already known on the subject: The development of multi‐purpose service programs to replace the older traditional rural hospitals is a relatively new practice in Australia. With the introduction of MPS programs there has been little evaluative research to demonstrate their effectiveness in health service delivery and the provision of residential aged care. Multi‐purpose service programs aim to integrate and coordinate acute, aged and community rural health services under one structure and so it is imperative that evaluative studies such as this one takes place. What does this study add?: The findings of this study demonstrate that the MPS model provides a better solution than hospitals to the problem of providing residential aged care in rural communities. With Australia looking to further develop MPS Programs in rural areas, it is hoped quality aged care services will be enhanced allowing older adults to remain in the communities of their choice.     

Public money, private control: a case study of hospital financing in Oakland and Berkeley, California

Government support of public and private hospitals in Oakland and Berkeley, California was investigated. The private hospitals received government subsidies amounting to at least 60 per cent of their total revenues. The dollar amount of the subsidies to private hospitals was four and one-half times greater than government expenditures on the public hospital. In Oakland and Berkeley, as in many cities, public medical services have been reduced while both government health expenditures and private hospital revenues have increased sharply. The private hospitals, although all nominally non-profit, exhibit revenue maximizing behavior which results in socially unjust and medically irrational resource allocation. Funds might be found for public hospitals and clinics, and resources allocated more justly and rationally, if government expenditures in the private sector were brought under greater public scrutiny and control.