Soft budget constraints in China: Evidence from the Guangdong hospital industry

Using data from 276 general acute hospitals in the Pearl River Delta region of Guangdong Province from 2002 and 2004, we construct a preliminary metric of budget constraint softness. We find that, controlling for hospital size, ownership, and other factors, a Chinese hospital’s probability of receiving government financial support is inversely associated with the hospital’s previous net revenue, an association consistent with soft budget constraints.      

Decision makers' views on health care objectives and budget constraints: results from a pilot study

Economic evaluations aim to inform policy makers about the costs and effects of medical interventions to support their decisions on the allocation of health care resources. Decision makers combine information on cost-effectiveness with their preferences and with possible constraints for the allocation of health care resources. That is, decision makers need to specify an optimality criterion and all possible (budget) constraints. Usually this is a more or less implicit process. The aim of our pilot study was to find out whether decision makers consider the objectives and budget constraints we selected for a theoretical model of resource allocation relevant, and to set priorities for these objectives.     

Informal payment for health care: evidence from Hungary

While there is a growing body of evidence that informal payments for health care are widespread and enduring in the former communist countries of Central and Eastern Europe and Central Asia, evidence on the scale of the phenomenon is not only limited, but what is available is often conflicting. Hungary exemplifies this controversy, as the available literature provides conflicting figures, differing by an order of magnitude among various surveys, with a similarly large difference between survey findings and expert estimates. This study advances understanding of the methodological issues involved in researching informal payments by providing a systematic analysis of the methodology of available empirical research and official statistics on the scale of informal payments in Hungary. The paper explores the potential sources of differences, to assess the scope to reduce the differences between various estimates and to define the upper and lower boundaries within which the true magnitude of informal payments can be expected to lie. Our analysis suggests that in 2001 the overall magnitude of informal payments lay between 16.2 and 50.9 billion HUF (euro 64.8- euro 203.6 million, US dollars 77.1-242.4 million), which amounted to 1.5-4.6% of total health expenditures in Hungary. Looked at this way, informal payments do not seem to be an important source of health care financing. However, as informal payments are unequally distributed among health workers, with the bulk of the money going to physicians, with some not taking any informal payments, family doctors and some specialists may have earned between 60 and 236% of their net official income from this source in 2001. This suggests that it is not the overall amount of informal payment that makes it a policy concern, but the consequences of its unequal distribution among health workers. What is remarkable about informal payments in Hungary is that a relatively small amount of money can keep the system running, which gives rise to the hypothesis that, in certain cases, it is the hope of substantial informal payments in the future that motivates physicians to remain in the system. This is a difficult challenge for policy-makers as it would require a much larger amount of money to achieve equilibrium under any formal alternative.     

Under-the-counter payments for health care: evidence from Bulgaria

Against a background of falling revenues and increasing expectations, health care systems in central and eastern Europe are facing increasing budgetary gaps. There is extensive anecdotal evidence that these gaps are being filled by informal or 'under-the-table' payments. These are important because of their implications for estimates of future funding requirements, for equity, and for the possible perverse incentives they introduce for those providing and managing health services. There is, however, relatively little information on either their scale or how they are perceived in these countries. We report the results of a small survey from Bulgaria that begins to address these issues. Data were collected by means of an interviewer-administered household survey in which those who had used state-provided health services in the preceding 2 years were identified. The survey took place throughout Bulgaria in 1994. One thousand people were approached and 706 (70.6%) provided information suitable for analysis; 42.9% had paid for services that were officially free. Payments had been for a wide range of services and to differing groups, including medical, nursing and ancillary staff. Payments to individuals during consultations were between 3% and 14% of average monthly income but the average cost of an operation was 83% of mean monthly income. There were large differences in the amounts paid by individuals. Most people were in favour of both official user fees and health care reform, except among the old, the poor, and those in poor health. Despite certain limitations, this study gives some indication of the scale of informal payments in Bulgaria. Several possibilities exist to address them. Contrary to what is often argued, there seems to be a popular willingness for them to be converted into formal co-payments. Before this can be done, there is a need for more research on the impact that this would have on equity and affordability.     

Institutional public private partnerships for core health services: evidence from Italy

Background  

Public-private partnerships (PPPs) are potential instruments to enable private collaboration in the health sector. Despite theoretical debate, empirical analyses have thus far tended to focus on the contractual or project dimension, overlooking institutional PPPs, i.e., formal legal entities run by proper corporate-governance mechanisms and jointly owned by public and private parties for the provision of public-health goods. This work aims to fill this gap by carrying out a comparative analysis of the reasons for the adoption of institutional PPPs and the governance and managerial features necessary to establish them as appropriate arrangements for public-health services provisions.     

Equity in health and health care in a decentralised context: evidence from Canada

The impact of administrative decentralisation on equity in health and health care is an important unresolved issue in the health policy debate. Predictions from the limited theoretical literature and the relevant empirical research are both insufficient to draw any firm conclusions. Many countries are nevertheless experimenting with decentralisation policies in the absence of research evidence. This paper presents an exploratory empirical analysis of decentralisation by investigating the spatial dimensions of health-related equity in Canada, a highly decentralised setting. Using data from the 2001 Canadian Community Health Survey, we apply a decomposition method of the Concentration Index to explore whether income-related inequalities in health and inequities in the use of health care are more likely to be due to gaps between rich and poor Canadian provinces rather than to differences between rich and poor individuals within them. The results show that within area variation is the most important source of income-related health inequality, while income-related inequities in health care use are mostly driven by differences between provinces.     

Indigent health care: the increasing contribution of AIDS to the health care budget deficit

With the number of AIDS cases in the United States exceeding 100,000 and rising, it is becoming more of a financial burden to take care of this population. The Regional Medical Center at Memphis, like most hospitals providing indigent care, sustains annually a large deficit for both outpatient and inpatient care of AIDS patients. With the establishment of a dedicated AIDS clinic, it is hoped to maximize outpatient care and the utilization of available financial resources. Implementation of this model may help obviate the financial disaster that is impending for the already overburdened public hospitals and their patients.     

Managed care and technology adoption in health care: evidence from magnetic resonance imaging

This paper empirically examines the relationship between HMO market share and the diffusion of magnetic resonance imaging (MRI) equipment. Across markets, increases in HMO market share are associated with slower diffusion of MRI into hospitals between 1983 and 1993, and with substantially lower overall MRI availability in the mid- and later 1990s. High managed care areas also had markedly lower rates of MRI procedure use. These results suggest that technology adoption in health care can respond to changes in financial and other incentives associated with managed care, which may have implications for health care costs and patient welfare.     

Strategic group stability: evidence from the health care industry

To better understand strategic group stability and the associated mobility barriers concept, we surveyed health care administrators on their reasons for remaining in their current strategic group. We offer administrators' responses to the strategic group stability (mobility barrier) question. Decision-makers may be unaware of these cognitive biases (e.g., group-level world-view and resource similarity) and may not recognize the extent to which they are reducing their strategic alternatives.     

Reforming health care: evidence from quantile regressions for counts

I consider the problem of estimating the effect of a health care reform on the frequency of individual doctor visits when the reform effect is potentially different in different parts of the outcome distribution. Quantile regression is a powerful method for studying such heterogeneous treatment effects. Only recently has this method been extended to situations where the dependent variable is a (non-negative integer) count. An analysis of a 1997 health care reform in Germany shows that lower quantiles, such as the first quartile, fell by substantially larger amounts than what would have been predicted based on Poisson or negative binomial models.     

Quality target negotiation in health care: evidence from the English NHS

We examine how public sector third-party purchasers and hospitals negotiate quality targets when a fixed proportion of hospital revenue is required to be linked to quality. We develop a bargaining model linking the number of quality targets to purchaser and hospital characteristics. Using data extracted from 153 contracts for acute hospital services in England in 2010/2011, we find that the number of quality targets is associated with the purchaser’s population health and its budget, the hospital type, whether the purchaser delegated negotiation to an agency, and the quality targets imposed by the supervising regional health authority.     

Agency in health care with an endogenous budget constraint

In this paper a doctor acts as a perfect agent for a group of patients in an environment where the health service is funded by a group of contributors. The contributor group donates resources to the health sector in accordance with its split preferences about the health care services which they would like for themselves and those which they would like for others. We show that the size of the health budget is endogenous and depends on the choices made by the doctor. The focus is on the division of the budget between health enhancing and non-health enhancing health care.     

Increasing research impact through partnerships: evidence from outside health care

There is growing interest in using closer partnerships between researchers and research users to increase the appropriate application of research evidence in policy and practice. While this supplement reports and assesses a number of these initiatives in health care, this article reviews the evidence in support of partnerships from elsewhere. Drawing on a substantial cross-sector review of research impact initiatives, we extract lessons for health care from partnership evaluations in social care, education and criminal justice services. A reasonable and robust evidence base supports the use of partnerships as one means of increasing research uptake. Although requiring substantial investments of time, resources and commitment, and suffering from a number of possible pitfalls, we conclude that such partnerships offer great potential for increasing research use.     

Free GP care and psychological health: Quasi-experimental evidence from Ireland

There is considerable ambiguity in the literature on the effect of health insurance on health. While the majority of previous analyses have examined physical health outcomes, analyses of the broader dimensions of health such as psychological health and wellbeing have been less frequent. Using data from the Irish Longitudinal Study on Ageing (TILDA) and a difference-in-differences research design, we examine the impact of free general practitioner (GP) care on psychological health among the older population and explore potential mechanisms. While we find no impact of public health insurance expansions on quality of life, life satisfaction, depression, and worry, the removal of GP fees for all those 70+ leads to a significantly lower level of perceived stress. The impact is mainly driven by poorer, sicker and single individuals. Further analyses show that removing GP fees leads to greater access to GP services and lower levels of financial stress.     

The effect of soft budget constraints on access and quality in hospital care

Given an increasingly complex web of financial pressures on providers, studies have examined how hospitals’ overall financial health affects different aspects of hospital operations. In our study, we develop an empirical proxy for the concept of soft budget constraint (SBC, Kornai, Kyklos 39:3–30, 1986) as an alternative financial measure of a hospital’s overall financial health and offer an initial estimate of the effect of SBCs on hospital access and quality. An organization has a SBC if it can expect to be bailed out rather than shut down. Our conceptual model predicts that hospitals facing softer budget constraints will be associated with less aggressive cost control, and their quality may be better or worse, depending on the scope for damage to quality from noncontractible aspects of cost control. We find that hospitals with softer budget constraints are less likely to shut down safety net services. In addition, hospitals with softer budget constraints appear to have better mortality outcomes for elderly heart attack patients.      

Evaluating antenatal care in Liberia: evidence from the demographic and health survey

Liberia has one of the highest maternal mortality ratios worldwide. Using quality antenatal care (ANC) can prevent maternal mortality. Indicators of quality ANC include: (1) timing of care initiation; (2) number of ANC visits (4+); and (3) ANC with recommended components. The purpose of this study was to examine factors associated with quality ANC in Liberia. Data from the 2013 Liberia Demographic and Health Survey were used (n = 5,348). Factors associated with quality ANC were assessed using multiple logistic regression. The majority of women attended at least four ANC visits (76.13%) and initiated care in the first trimester (66.5%); however, only 30% received care with all recommended components. Intended pregnancy, contraceptive use, and receiving ANC at a health facility with skilled providers were significantly associated with quality care. The lack of quality ANC may contribute to the high maternal mortality in Liberia. Facilitating access to health facilities and skilled ANC providers could improve the quality of care and potentially improve maternal outcomes over time. Additionally, focusing on empowering women with respect to access to birth control and control over pregnancies may increase the use of quality care.     

Integrated care models and behavioral health care utilization: Quasi‐experimental evidence from Medicaid health homes

Integration of behavioral and general medical care can improve outcomes for individuals with behavioral health conditions—serious mental illness (SMI) and substance use disorder (SUD). However, behavioral health care has historically been segregated from general medical care in many countries. We provide the first population‐level evidence on the effects of Medicaid health homes (HH) on behavioral health care service use. Medicaid, a public insurance program in the United States, HHs were created under the 2010 Affordable Care Act to coordinate behavioral and general medical care for enrollees with behavioral health conditions. As of 2016, 16 states had adopted an HH for enrollees with SMI and/or SUD. We use data from the National Survey on Drug Use and Health over the period 2010 to 2016 coupled with a two‐way fixed‐effects model to estimate HH effects on behavioral health care utilization. We find that HH adoption increases service use among enrollees, although mental health care treatment findings are sensitive to specification. Further, enrollee self‐reported health improves post‐HH.