Extending transaction cost economics: towards a synthesised approach for analysing contracting in health care markets with experience from the Australian private sector

Transaction cost economics (TCE) has been the dominant economic paradigm for analysing contracting, and the framework has been applied in a number of health care contexts. However, TCE has particular limitations when applied to complex industry settings and there have been calls to extend the framework to incorporate dynamic theories of industrial organisation, specifically the resource-based view (RBV). This paper analyses how such calls for theoretical pluralism are particularly germane to health care markets and examines whether a combined TCE-RBV provides a more comprehensive approach for understanding the nature of contractual arrangements that have developed within the Australian private health care sector and its implications for informing policy. This Australian case study involved a series of interviews with 14 senior contracting executives from the seven major health funds (i.e. 97% of the insured population) and seven major private hospital groups (i.e. 73% of the private hospital beds). Study findings reveal that both the TCE perspective with its focus on exchange hazards, and the RBV approach with its emphasis on the dynamic nature of capabilities, each provide a partial explanation of the developments associated with contracting between health funds and hospital groups. For a select few organisations, close inter-firm relational ties involving trust and mutual commitment attenuate complex exchange hazards through greater information sharing and reduced propensity to behave opportunistically. Further, such close relational ties also provide denser communication channels for creating and transmitting more complex information enabling organisations to tap into each other's complementary resources and capabilities. For policymakers, having regard to both TCE and RBV considerations provides the opportunity to apply competition policy beyond the current static notions of efficiency and welfare gains, and cautions policymakers against specifying ex ante the specific nature of contractual arrangements that ought to prevail in health care markets.     

A two-tiered public-private health system: Who stays in (private) hospitals in Ireland?

Despite efforts to create a universal, single-tiered Irish health system, an unequal "two-tiered" system persists. The future blueprint for Irish health care, Sláintecare, recommends a separation of public and private hospital treatment. This study examines patterns of overall and private hospital utilisation in Ireland that could help identify some of the impacts of the proposed separation of public and private hospital treatment. Using data from EU-SILC (2016) (n = 10,131) the factors associated with inpatient hospitalisation and private inpatient hospitalisation are estimated using probit models.Unsurprisingly, those who are economically inactive are more likely to have had an inpatient stay. Furthermore, those aged over 65, with a chronic illness, with a medical/ GP visit card and private health insurance and those with only private health insurance are also more likely to have had an inpatient stay. Those with only primary education are less likely to report an inpatient stay in private hospital. Those aged over 25 and less than 65, those with a medical/ GP visit card and private health insurance and those with only private health insurance are significantly more likely to opt for a private hospital. Understanding overall and private hospital utilisation patterns is imperative for implementing universal health care and associated resource planning and fulfilling policy recommendations.     

我国西部地区民营医院市场份额的熵权TOPSIS法评价研究

目的 明确医疗领域市场份额的内涵和外延,构建民营医院市场份额评价指标体系,分析我国西部十二个省、直辖市、自治区民营医院市场占有率,并探寻其主要的影响因素。方法 从医疗服务数量和服务收入两个层面构建民营医院市场份额评价指标体系,运用熵权TOPSIS法构建加权决策矩阵,找出有限方案中的最优和最劣方案,计算各评价对象与最优和最劣方案间的距离,进而获得评价对象与最优方案的相对接近程度,并以此作为评价排序的依据。结果 民营医院市场份额的熵权TOPSIS指数平均值为0.3921,综合评价排名最高的是西藏（0.9031）,最低的是广西（0.0438）。民营医院市场份额指标中权重较大的是民营医院住院药品收入比（0.1192）、住院检查费用收入比（0.1345）、住院手术费用收入比（0.1211）和住院其他费用收入比（0.1117）。结论 民营医院市场份额整体水平较低,且地区间存在较大差异;住院药品收入比、住院检查费用收入比、住院病人手术费用收入比和住院其他费用收入比是影响民营医院市场份额的主要因素。     

中国社会办医的现状分析

通过系统分析中国社会办医的现状,为进一步促进社会办医提出政策建议。根据国内外文献,社会办医疗机构和公立医疗机构在医疗费用和服务质量方面并没有显著差异,并且由于社会办医促进市场开放与公平竞争,公立医院和整个医疗卫生服务市场的绩效也因此有所提高（正向溢出效应）。尽管如此,由于中国长期计划经济自上而下的资源配置与行政干预,社会办医长期未能得到健康发展,主要政策障碍包括准入方面存在隐形限制、经营方面缺乏税收鼓励、用人方面缺少优质医师资源。因此,建议调整区域卫生规划的功能从“封顸”向“兜底”过渡,尽快制定有利于社会办医的土地政策和人才政策,进一步完善相关配套措施,促进社会办医在中国的健康发展。     

Knowledge,attitudes, and practices of private sector immunization service providers in Gujarat,India

BackgroundIndia is responsible for 30% of the annual global cohort of unvaccinated children worldwide. Private practitioners provide an estimated 21% of vaccinations in urban centers of India, and are important partners in achieving high vaccination coverage.MethodsWe used an in-person questionnaire and on-site observation to assess knowledge, attitudes, and practices of private immunization service providers regarding delivery of immunization services in the urban settings of Surat and Baroda, in Gujarat, India. We constructed a comprehensive sampling frame of all private physician providers of immunization services in Surat and Baroda cities, by consulting vaccine distributors, local branches of physician associations, and published lists of private medical practitioners. All providers were contacted and asked to participate in the study if they provided immunization services. Data were collected using an in-person structured questionnaire and directly observing practices; one provider in each practice setting was interviewed.ResultsThe response rate was 82% (121/147) in Surat, and 91% (137/151) in Baroda. Of 258 participants 195 (76%) were pediatricians, and 63 (24%) were general practitioners. Practices that were potential missed opportunities for vaccination (MOV) included not strictly following vaccination schedules if there were concerns about ability to pay (45% of practitioners), and not administering more than two injections in the same visit (60%). Only 22% of respondents used a vaccination register to record vaccine doses, and 31% reported vaccine doses administered to the government. Of 237 randomly selected vaccine vials, 18% had expired vaccine vial monitors.ConclusionsQuality of immunization services in Gujarat can be strengthened by providing training and support to private immunization service providers to reduce MOVs and improve quality and safety; other more context specific strategies that should be evaluated may involve giving feedback to providers on quality of services delivered and working through professional societies to adopt standards of practice.     

部分国家商业健康保险发展的特点及对我国的启示

本文分析了当前我国地方政府融资存在的财政自给率不足、对转移支付依赖加大、土地资源出让收入倾向最大化、地方政府债务隐性化和可持续贷款能力受限等问题,认为应正视未来20年我国地方政府在城市化进程中大规模融资行为的必然性,建议从五个方面入手来规范地方政府的融资行为,即以培育地方主体税种为基石深化分税制改革,以公共服务均等化为导向优化转移支付制度,通过正确处理土地出让金收入改变卖地财政境况,以地方政府债券发行收入来弥补市政建设缺口,以及鼓励符合条件的政府投融资平台上市融资等。     

上海市某区企业职业卫生管理的定性分析

目的描述上海市某区企业职业卫生管理的现况,客观、全面地评价职业卫生管理的优点与不足,为以后职业卫生监督管理决策的制定提供依据。方法采用卫生服务入户调查的方法,通过半结构化访谈收集定性资料,运用扎根理论进行分析。结果卫生执法人员、企业管理者等相关各方,在职业卫生监督管理方面存在许多共识和差异,尤其在监督频次、工作场所检测频次、防护用品佩戴、职业健康监护、预评价等方面分歧较大。结论建议严格贯彻现行法律法规,从监管模式、培训方式上寻找突破口,在保障劳动者权益的同时,适当考虑到企业利益,从而形成长效的职业卫生管理机制。     

Private medicine in socialist China: A survey of the private medical market in Guangzhou

This study analyses the size and the characteristics of the private medical market in Guangzhou. Legislations related to the regulation of private medical establishments are examined. Data collected reveal that private sector provision of health services in China is still small and lacks sophistication. The article recommends further reforms in the fees and charges system; loosening of the restrictions of public doctors to undertake private practice; contracting-out some of the state health services to private practitioners; and, creating a more favourable environment for private investment in the health care industry.     

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.     

民营医院发展对中国公立医院运营效率的作用机制研究——基于Malmquist-Tobit工具的实证分析

目的:分析民营医院发展对公立医院运营效率的作用机制及大小。方法:利用Malmquist-Tobit工具实证分析民营医院发展对公立医院运营效率的影响。结果:2010—2015年中国公立医院全要素生产率指数均值为1.036,技术进步和技术效率贡献率分别为66.7%、33.3%。全要素生产率与技术进步、技术效率相关系数为0.328、0.742。民营医院结构优化对公立医院运营效率具有显著抑制效应,民营医院核心资源为显著促进效应,民营医院机构数量和产业规模作用不显著。结论:中国公立医院运行效率整体处于改善阶段,不规则负增长与区域、省际分化并存。技术进步和技术效率双路径驱动运营效率提升。民营医院发展对公立医院运营效率作用机制表现为民营与公立医院结构性竞争框架下蕴含的异质性、非对称性和门限特征。     

Integration and retention of American physician assistants/associates working in English hospitals: A qualitative study

BackgroundHealth workforce planners in many high-income countries are considering policy strategies to retain home and overseas-trained health professionals. There is a lack of evidence on how hospitals can successfully integrate and retain skilled overseas professionals in relevant work roles. This study aimed to explore the integration and retention experiences of skilled American physician assistants/associates working in English hospitals.MethodsA qualitative study using semi-structured telephone interviews was undertaken in spring 2017 and spring 2018. Data were coded and analysed using thematic analysis. The study was framed within a theoretical model of role development.ResultsNineteen physician assistants/associates participated in interviews at timepoint one, and seventeen at timepoint two, across seven English hospitals. Four themes were identified in the integration and retention processes experienced by participants: motivations and expectations, seeking role identity, acceptance and integration, and establishing a niche role. Supervising doctors appeared instrumental in creating opportunities through training and system adjustment that enabled development of niche roles; offering an effective match between participant skills and interests, and medical/surgical team or organisational needs. Whether or not they had a niche role influenced the decision of participants to remain or leave.ConclusionIntegration approaches that maximise the value of the skilled health professional to the medical/surgical team and support retention, including development of optimum roles, require time and resources.     

Utilization of HIV-related services from the private health sector: A multi-country analysis

Increasing the participation of the private health sector in the AIDS response could help to achieve universal access to comprehensive HIV prevention, treatment, care and support. Yet little is known about the extent to which the private health sector is delivering HIV-related services. This study uses data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 12 countries in Africa, Asia and Latin America and the Caribbean to explore use of HIV testing and STI care from the private for-profit sector, and its association with household wealth status. The analysis indicates that the private for-profit health sector is active in HIV-related service delivery, although the level of participation varies by region and country. From 3 to 45 percent of women and 6 to 42 percent of men reported the private for-profit sector as their source of the most recent HIV testing. While in some countries, use of the private for-profit health sector for HIV testing and STI care increases with wealth, in others the relationship is not clear, as there are no significant differences in using private for-profit HIV-related services between the rich and the poor. We conclude that as the global AIDS response evolves from emergency relief to sustained country programs, broader consideration of the role of the private for-profit health sector may be warranted.     

Outsourcing vaccine logistics to the private sector: The evidence and lessons learned from the Western Cape Province in South-Africa

With few exceptions, immunization supply chains in developing countries continue to face chronic difficulties in providing uninterrupted availability of potent vaccines up to service delivery levels, and in the most efficient manner possible. As these countries struggle to keep pace with an ever growing number of vaccines, more and more Ministries of Health are considering options of engaging the private sector to manage vaccine storage, handling and distribution on their behalf. Despite this emerging trend, there is limited evidence on the benefits or challenges of this option to improve public supply chain performance for national immunization programmes. To bridge this knowledge gap, this study aims to shed light on the value proposition of outsourcing by documenting the specific experience of the Western Cape Province of South Africa. The methodology for this review rested on conducting two key supply chain assessments which allowed juxtaposing the performance of the government managed segments of the vaccine supply chain against those managed by the private sector. In particular, measures of effective vaccine management best practice and temperature control in the cold chain were analysed. In addition, the costs of engaging the private sector were analysed to get a better understanding of the economics underpinning outsourcing vaccine logistics. The results from this analysis confirmed some of the theoretical benefits of outsourcing to the private sector. Yet, if the experience in the Western Cape can be deemed a successful one, there are several policy and practice implications that developing countries should be mindful of when considering engaging the private sector. While outsourcing can help improve the performance of the vaccine supply chain, it has the potential to do the reverse if done incorrectly. The findings and lessons learnt from the Western Cape experience can serve as a step towards understanding the role of the private sector in immunization supply chain and logistics systems for developing countries.     

Health insurance and private providers: A study of the civil servants' medical benefit scheme in bangkok,Thailand

Compulsory health insurance schemes have received attention recently as a means of creating a reliable extra-budgetary source of health care funding. Yet, the full implications of such schemes in a developing country context are unclear; in particular, the impact on and relationship with private sector providers has infrequently been explored. This study examines patterns of public and private sector utilization under the Civil Servants' Medical Benefit Scheme (CSMBS) in Bangkok, Thailand. The CSMBS currently provides limited reimbursement for private inpatient care, but recent proposals suggest increasing benefit levels for care sought in the private sector. The study shows that despite high level of cost recovery in the public sector, charges were much lower than those in the private sector. Different patterns of diagnosis in the two sectors were found with private hospitals tending to treat a less complex case mix. Within the private sector, there was a limited tendency to specialize in certain types of care. It is concluded that under the current payment mechanism of fee-for-service reimbursement, measures to enhance access to private sector care should be approached with caution. In the long run, the scheme should merge with the recently established social security scheme.     

中国动物源性传染病防制多部门合作现状调查研究

目的调查我国动物源性传染病防制中部门间合作现状及问题，探索有效的多部门合作机制。方法定性定量研究相结合，通过文献检索、问卷调查、小组讨论、关键人物访谈等方法，对相关部门合作现状及问题进行调查。结果动物源性传染病防制主要参与部门是卫生、农业部门，各部门工作深度和介入程度不同，部门间信息尚未实现共享。政府对卫生资源配置不合理，基层部门防疫经费严重短缺。政府应利用权力和决策优势，加强对多部门合作的领导和监管，动员全社会共同参与。结论动物源性传染病防制应以政府主导，卫生、农业部门为主，多部门共同参与。     

湛江市非公有制企业妇女病普查结果分析

目的: 了解湛江市非公有制企业女职工生殖健康状况, 制定有效的防护措施。方法: 回顾分析 1 000例妇科病、乳腺疾病普查。结果: 已婚女职工妇检率城区高于郊区, 成年妇女主要患病率顺序为阴道炎 26. 04%, 宫颈炎 22 68%, 乳腺疾病 13 .50%, 子宫肌瘤 4 .56%, 慢性盆腔炎 2 .01%。结论: 以防治生殖道感染为中心, 同时关注子宫颈癌, 提高妇女自我保健能力是当前妇女保健工作的重要任务。     

Once covered,forever covered: The actuarial challenges of the Belgian private health insurance system

The Belgian Law of 20 July 2007 has drastically changed the Belgian private health insurance sector by making individual contracts lifelong with the technical basis (i.e. actuarial assumptions) fixed at policy issue. The goal of the Law is to ensure the accessibility to supplementary health coverage in order to protect policyholders from discrimination and exclusion, essentially when these operate on the basis of age. Due to the unpredictable nature of medical inflation risk and the difficulty to model future increases of health claims, the legislator introduced medical indices together with a specific updating mechanism, which aim at establishing standardized and fair premium adjustments across the sector. This paper considers two major issues of the current Belgian system. The first one is related to the transferability of the reserves, whereas the second one is related to age-discrimination. We discuss these issues and their interplay, and we address the conflict between the goal of the Law and the practical problems arising in the light of the actuarial techniques.     

The changing role of the occupational physician in the private sector: the Canadian experience

The role of the occupational physician in the private sectoris changing. Fewer large corporations maintain medical departmentsfollowing the ‘downsizing’ trend of the late 1980'sand early 1990's and those that do have extensively redefinedthe duties of the corporate medical director, often extendingthese duties to include responsibility for environmental health.Occupational medical services for employees previously coveredby in-house services are now often provided by outsourcing.The private practice of occupational medicine has become themajor growth area of the speciality in both the US and Canada.These trends have been driven primarily by economic imperativesand new management philosophies; the trend may have gone toofar and a ‘rightsizing’ correction may be in progress.However, it is not clear that corporations in general are derivingthe greatest value they can from their physicians or that thecurrent generation of senior managers is utilizing its healthprofessionals as effectively as they might. This is in partbecause the training, qualifications and capabilities of occupationalphysicians are not well understood. At least as important, however,is persistent confusion over desirable and appropriate rolesthat obscures the potential contribution of the medical professionalwithin a management structure. We suggest that the greatestvalue in occupational medical services may be in the anticipationof risk related to health issues and the flexibility this givesthe organization to manage the problem.     

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.     

Contextualising health seeking behaviours for febrile illness: Lived experiences of farmers in northern Tanzania

Understanding how people seek treatment for febrile illness can provide important insights into when care is sought and under what circumstances. This is includes examining how people engage with health facilities and the barriers to care they experience. However, a focus on individual actions runs the risk of overemphasising the agency of individuals to make apt health decisions while underestimating the ways which health behaviours are circumscribed by their place-specific social, historic and political contexts. Drawing on the experiences of approximately 100 farmers in a small livestock keeping community in northern Tanzania, this study uses biosocial theory of health to better understand how febrile illness is managed among individuals. The paper draws attention to the ways in which health decisions are mediated by individual, intrinsic and extrinsic health system factors. Some extrinsic factors (such as hospital user fees) are legacies of neoliberal healthcare reform policies which continue to have consequences for how people manage febrile illness in Tanzania. The findings highlight the need for considerations of health behaviours to look beyond the individual and to appreciate the role of the wider health landscape in influencing individual choice and agency when seeking treatment for illness.