Differences between public and private hospital care in Spain: the realities of health care or a numerical fallacy?

OBJECTIVE: To give an example of the misleading interpretations of the concepts "public and private" when dealing with simple data from hospital resources and activities in Spain. MATERIAL AND METHODS: Data comes from the survey of hospitals (EESCRI) for the year 2002 in Catalonia. Using the figures corresponding to resources (number of centers and beds) and activities (discharges, stays, mean stay, occupancy, and rotation) comparisons are made among different variables (managing authority and funding source) reclassified, according to the concepts of public and private. RESULTS: The figures on resources and activities offer a very different portrait about the public or private nature of the care provided, according to the variables being used for classification. CONCLUSIONS: It is necessary to specify the concepts and variables to be used when analyzing the performance of health services and to improve the information sources in order to adapt them to the new management forms of the health services.     

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.     

Is the Colombian health system reform improving the performance of public hospitals in Bogotá?

Many countries are experimenting with public hospital reform - both increasing the managerial autonomy with which hospitals conduct their affairs, and separating 'purchaser' and 'provider' sides of the health system, thus increasing the degree of market pressure brought to bear on hospitals. Evidence suggesting that such reform will improve hospital performance is weak. From a theoretical perspective, it is not clear why public hospitals should be expected to behave like firms and seek to maximize profits as this model requires. Empirically, there is very slight evidence that such reforms may improve efficiency, and reason to be concerned about their equity implications. In Colombia, an ambitious reform programme includes among its measures the attempt to universalize a segmented health system, the creation of a purchaser-provider split and the transformation of public hospitals into 'autonomous state entities'. By design, the Colombian reform programme avoids the forces that produce equity losses in other developing countries. This paper reports the results of a study that has tried to track hospital performance in other dimensions in the post-reform period in Bogotá. Trends in hospital inputs, production and productivity, quality and patient satisfaction are presented, and qualitative data based on interviews with hospital workers are analyzed. The evidence we have been able to collect is capable of providing only a partial response to the study question. There is some evidence of increased activity and productivity and sustained quality despite declining staffing levels. Qualitative data suggest that hospital workers have noticed considerable changes, which include greater responsiveness to patients but also a heavier administrative burden. It is difficult to attribute specific causality to all of the changes measured and this reflects the inherent difficulty of judging the effects of large-scale reform programmes as well as weaknesses and gaps in the data available.     

A new approach to global health institutions? A case study of new vaccine introduction and the formation of the GAVI Alliance

There is an emerging research agenda to analyse empirically the forces driving changes in global health governance. This study applies analytical tools from international relations research to explain the formation of international health regimes. The study utilizes two explanatory perspectives: individual leadership, and the interests of key non-state actors in the formation process, using the case of the formation of the Global Alliance for Vaccines and Immunization (GAVI) from 1995 to 1999. The case study is based on material from interviews with key actors, an archival review of documents from the Children’s Vaccine Initiative (CVI), and published literature. Findings show that the regime formation process was initiated by individuals who were primarily affiliated to scientific communities and who led to the World Bank and the Gates Foundation becoming champions of a new coordinating mechanism for new vaccine introduction. Negotiations in the regime formation process were between a small group of founding agencies with divergent interests regarding immunization priorities. The case also sheds light on the authority of the WHO and the resources of the Gates Foundation in driving the process towards the final structure of the alliance. The paper discusses the potential contribution of the international relations approach compared to policy research as a way of understanding the institutional dynamics of global health, particularly in respect of relations between countries and non-state actors.     

Does federal health care policy influence switching between the public and private sectors in individuals?

OBJECTIVE: The aim of this study was to determine if changes in Australian Federal health policy have influenced individual behaviour regarding utilisation of private health insurance in Western Australia. METHOD: The WA Data Linkage System was used to extract all hospital morbidity records in Western Australia from 1980 to 2001. For each individual, episodes were grouped into hospital couplets classified according to the mix of public and privately insured events. Logistic regression was used to estimate the likelihood of switching towards or away from the private sector, according to the time between episodes in each of five health care policy eras. RESULTS: The odds of a switch away from the private sector increased by 29% with each additional year between episodes, while the odds of a switch towards the private sector increased by 15% per intra-couplet year. In those with a private first episode the odds of switching decreased approximately exponentially across the five eras whereas the odds of switching in those with a public first episode stabilised after 1985. In the last era (1999-2001) the odds of switching away from the private sector reduced substantially. CONCLUSION: Our analysis suggests that the recent policies supporting PHI (30% rebate and Lifetime Health Cover) appear to have been effective at modifying individual behaviour to reduce the drift away from the private sector. However, the reported increases in utilisation of PHI were only partially explained by switching of existing demand in patients who had been previously hospitalised as public patients, suggesting that the policy reforms had generated, rather than merely shifted, demand for health care. This finding has significant policy implications for Australia.     

Is the self‐reported private health insurance status in the National Health Survey representative of private health insurance coverage in Australia?

Objective: This study determines whether the distribution of self‐reported private health insurance (PHI) status in the 2004/05 National Health Survey (NHS) is representative of PHI coverage in Australia. Methods: Weighted estimates from the NHS 2004/05 are compared with PHI status reported for 2004/05 by the Private Health Insurance Administration Council (PHIAC, the independent regulator of the private health insurance industry). PHI status was imputed to children in the NHS based on PHI status of the adult in the household. The two data sources were deemed to be different if the PHIAC results were not within the 95% CI range for the NHS estimate. Results: PHI status reported in the NHS and PHIAC are generally comparable except for some categories such as hospital cover of males aged 5–9 years and females aged 85 years and older where the NHS estimates are below PHIAC numbers; and males aged 25–29, 35–39, and 50–54 years where the NHS estimates are higher. Conclusions: The findings suggest that while the NHS 2004/05 estimates may accurately represent coverage in Australia particularly when examined at an aggregated level, there is some variation in the NHS estimates when examined by sex and age group. Implications: Researchers need to be aware of the potential for sampling and reporting bias to contribute to some misrepresentation of PHI status when using the NHS to generalise to the Australian population. Exploring corrective measures will ensure that the NHS continues to be a valuable data resource for health researchers in Australia.     

Men's health promotion: a new frontier in Australia and the UK?

The field of men's health has grown markedly over the past few decades. Increased activity specifically relating to men's health promotion in both Australia and the UK has been noted during this period. There has, however, been a reticence to critically examine men's health promotion work within a broader discourse relating to gender and gender relations. Indeed, the vast majority of health-related gender discussion to date has been focused on women's health experiences and their health practices. In this paper, we argue that grounding men's health within this broad gender discourse is important for building an evidence base in, and advancing, men's health promotion work at a range of levels. We specifically explore the research, practice and policy contexts relating to men's health in Australia and the UK, and describe the facilitators for, and barriers to, promoting men's health. We conclude by suggesting that a critical gender lens ought to be applied to current men's health promotion work and provide strategies for researchers, practitioners and policy makers to move towards this new frontier.     

Doing mini-health technology assessments in hospitals: a new concept of decision support in health care?

OBJECTIVES: The purpose of this project was to evaluate local decision support tools used in the Danish hospital sector from a theoretical and an empirical point of view. METHODS: The use of local decision support was evaluated through questionnaires sent to all county health directors, all hospital managers, and all heads of clinical departments in cardiology, orthopedic surgery, and intensive care. In addition, respondents were asked to submit whatever decision support tools they were using (including mini-HTAs, other forms or checklists, and special procedures for decision making concerning new health technologies). A theoretical analysis of the decision support tools (decision theory) was performed as well as a comparison with the business case method used in private companies. Finally, the Danish mini-HTA was compared with foreign production and use of HTA and HTA-like assessments as local decision support. RESULTS: The response rate was high (87 percent, 94 percent, 85 percent, respectively). We collected sixty different forms (of which forty-nine were mini-HTAs) and twenty variants of written procedures. We found theoretical and empirical evidence that local involvement in the process of making the HTA could be important for the use of the results from the HTA and for the process of implementing the new technology. CONCLUSIONS: Doing mini-HTA in hospitals seems to balance the need for quality and depth with the limited time and resources for assessment.     

Does diverse staff and skill mix of teams impact quality of care in long-term elderly health care? An exploratory case study

Objectives

Many European countries face challenges in long-term care for older people, such as the growing number of older people requiring care, the increasing complexity of their health care problems, and a decreasing workforce that is inadequately prepared. Optimizing the staff and skill mix of health care teams may offer part of the solution for these challenges. The aim of this study was to obtain insight into the development of teams in terms of staff and skill mix, and the influence of staff and skill mix on quality of care, quality of life, and job satisfaction.

Methods

Seven teams in elderly care in the Netherlands participated in this exploratory case study. From April 2013 to January 2015, a researcher followed the development of the teams, performed observations at the workplace and held interviews with team members, team captains, and (representatives of) clients. Data-analyses were carried out in MAXQDA 11, by coding interviews and analyzing themes.

Results

During the project, almost all teams became more diverse in terms of staff and skill mix. In general, there was a trend towards adding (more) higher-qualified health care workers (e.g. nurse) to the team, increasing communication with other disciplines, and enhancing skills of lower-qualified team members. A more diverse staff and skill mix had a positive effect on quality of care and quality of life of clients, and on job satisfaction, but only under certain contextual conditions. Important contextual conditions for successful functioning of a diverse team were a shared view of care by all team members, good communication, autonomy for professionals, and a safe team culture.

Conclusion

A more diverse staff and skill mix, in combination with positive contextual conditions, can result in improved quality of care, quality of life, and job satisfaction. However, a “one size fits all” blueprint for the optimal staff and skill mix, that suits each team and organization, does not exist. This depends on the context, and should be based on the needs of the clients and possible future changes in these needs.

     

What constitutes success in preventive health care? A case study in assessing the benefits of hip protectors

The economic success of preventive health programs is typically assessed by the net health-related utility gain or loss to society relative to the cost. Issues relating to the positive or negative utility associated with participating in a preventive health program are often ignored. However, it is likely that calls for informed consumer choice and respect for patient autonomy will provide an impetus to examine utility associated with the process and outcomes of preventive health programs. In this paper, we outline the nature of the ex ante and ex post perspective in evaluating benefits and the presence of process utility and the utility of gambling in individual's utility function for preventive health care. The implications of including process attributes and psychological states when assessing benefits to society are discussed in relation to an empirical study on the value of external hip protectors for the prevention of hip fractures. We demonstrate that wearing hip protectors and the psychological outcomes of being a participant in the program can have a significant impact on individual's assessment of the benefits. Furthermore, point of reference plays a crucial role in their valuation. Individuals who did not consent to participate in a trial of hip protectors valued all states significantly lower than those who did participate in the trial. We argue that the utility associated with adherence to the intervention is an important issue for preventive health policy. From the viewpoint of applied welfare economics, evaluation of preventive health programs should allow for both process and outcome utility when assessing benefits. In this context, success might be viewed as maximising the opportunity for individuals to make an informed choice.     

Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system

Major reforms of the health insurance system and reimbursement systems for care providers are currently taking place in The Netherlands. These market-oriented health care reforms will transform the current central supply-driven system to a system of managed competition both among health care insurers and care providers. The reforms are not systematically linked to the discussions about quality of care and together with consumers who might be more interested in lower premiums; they offer almost no incentive for health care insurers and providers to steer on quality. Dutch policy makers should, therefore, be more explicit whether competition should take place on quality or price, and if the former is the case, additional incentives as part of the system reforms, are needed to create a business case for quality.     

Belgium’s mixed private/public health care system and its impact on the cost of end-stage renal disease

Belgium has a mixed, public–private health care system, with state-organized reimbursements but private providers. The system is fee for service. For end-stage renal disease (ESRD), the fee-for-service system discourages preventive strategies, early referral to the nephrology unit, and the use of home-based therapies. The aging of the general population is reflected in the rapidly increasing number of very old dialysis patients, requiring more complicated and, therefore, more costly care. As dialysis costs increase, the ability to provide unrestricted access to dialysis treatment may be unsustainable. To aid in decision-making processes, nephrologists must be aware of financial and organizational issues.      

Do preferences differ based on respondent experience of a health issue and its treatment? A case study using a public health intervention

The European Journal of Health Economics - Preference information is increasingly being elicited to support decision-making. Although discrete choice experiments (DCEs) are commonly used, little is...     

Is the United States an outlier in health care and health outcomes? A preliminary analysis

U.S. health care is often seen as an outlier, with high costs and only middling outcomes. This view implies a household production function for health, with both health care and lifestyle serving as inputs. Building on earlier work by Miller and Frech (2004), we make this argument explicit by estimating a production function from augmented OECD data. This allows us to determine whether the U.S. is literally an outlier; which turns on whether the United States is very far off the production surface. We find that the Unites States is somewhat less productive than the average OECD country, but that a substantial part of the observed difference results from poor lifestyle choices, particularly obesity. JEL Classification I12 . I18 Earlier versions of this paper were presented at UCLA on May 29, 2003 and at a Conference on Health and Economic Policy in Munich, Germany on June 27, 2003. Thanks are due to the participants of those sessions for helpful comments, and especially to Tom Rice at UCLA. We also appreciate the excellent research assistance of Andrea Lehman.