Markets for hospital services in Zambia

Hospital reforms involving the introduction of measures to increase competition in hospital markets are being implemented in a range of low and middle-income countries. However, little is understood about the operation of hospital markets outside the USA and the UK. This paper assesses the degree of competition for hospital services in two hospital markets in Zambia (Copperbelt and Midlands), and the implications for prices, quality and efficiency. We found substantial differences among different hospital types in prices, costs and quality, suggesting that the hospital service market is a segmented market. The two markets differ significantly in their degree of competition, with the high cost inpatient services market in Copperbelt relatively more competitive than that in the Midlands market. The implications of these differences are discussed in terms of the potential for competition to improve hospital performance, the impact of market structure on equity of access, and how the government should address the problem of the mine hospitals.     

The Ambiguous Effect of GP Competition: The Case of Hospital Admissions

In the theoretical literature on general practitioner (GP) behaviour, one prediction is that intensified competition induces GPs to provide more services resulting in fewer hospital admissions. This potential substitution effect has drawn political attention in countries looking for measures to reduce the growth in demand for hospital care. However, intensified competition may induce GPs to secure hospital admissions a signal to attract new patients and to keep the already enlisted ones satisfied, resulting in higher admission rates at hospitals. Using both static and dynamic panel data models, we aim to enhance the understanding of whether such relations are causal. Results based on ordinary least square (OLS) models indicate that aggregate inpatient admissions are negatively associated with intensified competition both in the full sample and for the sub‐sample patients aged 45 to 69, while outpatient admissions are positively associated. Fixed‐effect estimations do not confirm these results though. However, estimations of dynamic models show significant negative (positive) effects of GP competition on aggregate inpatient (outpatient) admissions in the full sample and negative effects on aggregate inpatient admissions and emergency admissions for the sub‐sample. Thus, intensified GP competition may reduce inpatient hospital admissions by inducing GPs to provide more services, whereas, the alternative hypothesis seems valid for outpatient admissions. © 2016 The Authors. Health Economics Published by John Wiley & Sons, Ltd.     

Do community hospitals reduce the use of district general hospital inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.     

THE DETERMINANTS OF HEALTH CARE EXPENDITURE TOWARD THE END OF LIFE: EVIDENCE FROM TAIWAN

This paper empirically investigates the relationship between the health care expenditure of end‐of‐life patients and hospital characteristics in Taiwan where (i) hospitals of different ownership differ in their financial incentives; (ii) patients are free to choose their providers; and (iii) health care services are paid for by a single public payer on a fee‐for‐services basis with a global budget cap. Utilizing insurance claims for 11 863 individuals who died during 2005–2007, we trace their hospital expenditures over the last 24 months of their lives. We find that end‐of‐life patients who are treated by private hospitals in general are associated with higher inpatient expenditures than those treated by public hospitals, while there is no significant difference in days of hospital stay. This finding is consistent with the difference in financial incentives between public and private hospitals in Taiwan. Nevertheless, we also find that the public–private differences vary across accreditation levels. Copyright © 2013 John Wiley & Sons, Ltd.     

Assessing performance of Taiwan hospitals using data envelopment analysis: In view of ownership

With rapid economic development in Taiwan, people have greater awareness of health care and are paying more attention to it. From the perspective of hospital management, the scale of hospitals and efficiency improvement are of concern to hospital managers. However, the extent of efficiency will differ between public and private hospitals due to their different ownership and goals. The study aims to evaluate the efficiency of public and private hospitals and to investigate the influence of ownership on efficiency of hospitals. The differences between hospitals can be understood by analyzing the features of the organization of hospitals and their geographic environment. In this way, hospitals with relatively low efficiency will be able to make improvements based on concrete evidence. By means of the two‐stage method, the efficiency scores of 182 hospitals in Taiwan are compared. In the first stage, the data envelopment analysis is applied to obtain the efficiency scores of hospitals. The results show that private hospitals are more efficient than public hospitals. In the second stage, Tobit regression is used to investigate the factors influencing efficiency obtained by the data envelopment analysis. The results indicate that there are differences between ownership in market competition and the average length of stay.     

The effect of network arrangements on hospital pricing behavior

The Department of Justice (DOJ) and the Federal Trade Commission (FTC) have taken a recent interest in collaborations among hospitals that do not entail common ownership, despite the lack of scientific evidence regarding effects of these hospital "networks" on market competition. This paper explores the relationship between hospital networks and pricing behavior in California during a period of dynamic increase in hospital network activity there. Using Herfindahl-Hirschman Indexes (HHI) market definitions based on patient origin and accounting for network relationships, we find a positive network effect on hospital pricing. However, this result appears to be generated primarily by system-owned hospitals that form networks to provide particular services jointly.     

美国营利和非营利医院的评价

美国营利和非营利医院的经营目的的不同，但在管理方法和市场竞争策略上正在逐步趋同。它们相互竞争，在医疗服务的价格上各有高低，总体上是有竞争的医院医疗服务的价格要高于没有竞争的医院。在扣除了税收、公共的补贴及慈善损助等之后进行的分析发现，营利医院和非营利医院的医疗服务成本各有高低，但营利医院的医疗服务的效率相对较 。两种类型的医院医疗服务的质量总体上没有差别。非营利医院提供了较多的社会医疗服务。     

Hospital and health maintenance organization financial agreements for inpatient services: a case study of the Minneapolis/St. Paul area.

With nearly a quarter of the population enrolled in Health Maintenance Organizations (HMOs) the Mineapolis/St. Paul metropolitan area provides a unique opportunity for studies dealing with the effects of prepaid health plans on the health care marketplace. This study explores one aspect of that market; discounts obtained by HMOs for hospital inpatient service. Using information gathered from structured interviews with the 7 HMOs and 30 hospitals in the Twin Cities area, the study addressed three areas of inquiry: (1) the nature of discount contracts between hospitals and HMOs, (2) the roles played by each party in initiating the contracts, and (3) factors influencing the establishment of the contracts. While each of the HMOs was found to have at least one hospital contract under which they received inpatient services for other than full-billed charges, the amount of the discount was not substantial in the majority of cases. Other factors such as hospital location and ability to provide a full range of services appear to be as important as financial discounts when HMOs select a hospital for inpatient services. It appears that hospitals played the lead role in initiating hospital/HMO contracts during the formative HMO years, but this initiative shifted to the HMOs as they gained market shares and bargaining power. Hospitals and HMOs agree that the most important factor influencing hospital willingness to consider discount contracts was and still is the surplus bed availability in the area. This surplus of beds has been exacerbated by a continued decline in hospital utilization. These conditions coupled with increased HMO market shares has recently resulted in intensified contract negotiations and further discounts for inpatient services.     

Does competition improve hospital performance: a DEA based evaluation from the Netherlands

Many countries have introduced competition among hospitals aiming to improve their performance. We evaluate the introduction of competition among hospitals in the Netherlands over the years 2008–2015. The analysis is based on a unique longitudinal data set covering all Dutch hospitals and health insurers, as well as demographic and geographic data. We measure hospital performance using Data Envelopment Analysis and distinguish three components of competition: the fraction of freely negotiated services, market power of hospitals, and insurer bargaining power. We present new methods to define variables for each of these components which are more accurate than previously developed measures. In a multivariate regression analysis, the variables explain more than half of the variance in hospital efficiency. The results indicate that competition between hospitals and the relative fraction of freely negotiable health services are positively related to hospital efficiency. At the same time, the policy measure to steadily increase the fraction of health services contracted in competition may well have resulted in a decrease in hospital efficiency. The models show no significant association between insurer bargaining power and hospital efficiency. Altogether, the results offer little evidence that the introduction of competition for hospital care in the Netherlands has been effective.

     

四川省医院市场结构的变化发展

利用2002—2017年四川省医院机构数据,从市场规模、市场份额和市场集中度方面分析医院市场结构的变化发展。结果:近年来医院数和床位数逐年上升,2002—2017年,医院总数从1 163所增长为2 219所,床位总数从118 593张增长为411 911张;医院数量的变化主要由一级公立医院的减少和一级民营医院增加引起。民营医院市场份额不断增加(2002—2017年床位、门诊服务、住院服务市场占比分别从3.71%、3.08%和3.12%增长为32.10%、17.78%和25.21%),但仍小于公立医院。医院市场竞争保持增大趋势,2017年约1.11%的医院市场处于完全竞争,11.11%垄断竞争,87.78%高度垄断。当前,公立医院继续主导医院市场,在新时代下,医疗供给侧改革的深化应仍然关注公立医院,同时尚有较大空间实施鼓励社会办医和促进竞争的相关政策。     

新型冠状病毒肺炎疫情对公立医院服务供给的影响 ——基于北京市F医院的实证研究

目的:分析新型冠状病毒肺炎疫情对公立医院医疗服务供给的影响.方法:使用北京市F医院2019年1月至2020年8月的月度住院医疗服务数据,应用间断时间序列回归分析方法,从住院医疗服务数量、服务结构、服务效率、费用水平四个方面分析住院医疗服务供给的变化.结果:疫情防控干预导致F医院住院医疗服务数量大幅降低,手术和重症患者比...     

Estimating hospital costs with a generalized Leontief function

This paper estimates a long-run hospital cost function with multiple outputs and inputs using a panel data set from Washington State hospitals during 1988-1993. We find that with our data the generalized Leontief function is more appropriate than a translog for estimating hospital cost functions. With respect to hospital costs, we find that hospitals readily adjust the use of intermediate products. Radiology, therapies and surgery, and other inpatient days, all serve as substitutes for core inpatient days. Outpatient services are found to be complementary to core inpatient services, indicating that the growth of stand-alone outpatient clinics might increase the costs of providing healthcare services. Our analysis finds that hospitals show significant economies of scale, but there is a limited amount of evidence of scope economies. Also, there is some evidence that profit-seeking hospitals achieve some of their goals by controlling costs, and that diagnostically related groups (DRG)-based Medicare services are effective in getting hospitals to control costs.     

Factors related to the provision of hospital discounts for HMO inpatients.

Using 1986 AHA hospital survey data, we analyzed hospital-HMO contract provisions, hospital operating characteristics, and market conditions for a national sample of 801 hospitals with HMO contracts to determine the factors related to provision of a discount and the magnitude of the discount if present. Seventy-eight percent of the hospitals reported that at least one of their HMO contracts provided a discount for inpatient services. Risk-sharing provisions, the number of hospitals within a five-mile radius, the proportion of the population enrolled in HMOs, and the number of HMOs operating in the metropolitan statistical area (MSA) were directly related to provision of discounts. Public hospitals were less likely than other facilities to provide discounts. For the magnitude of the discounts, risk-sharing provisions and the number of hospitals within a five-mile radius were again related, as was the number of HMOs operating in the MSA--but this time the number-of-HMOs variable had an inverse relationship. The results suggest that increased HMO market activity does result in price competition for hospital services but that hospital discounting strategies are extremely complex and may not follow conventional market theories. Hospitals appear to be using contracts both to stabilize their relationships with HMOs and increase market share, and they are increasingly giving discounts to achieve those ends.     

Effects of market position and competition on rural hospital closures.

OBJECTIVE: To examine the dynamic effects of competition and hospital market position on rural hospital closures. DATA SOURCE/STUDY SETTING: Analysis of all rural community hospitals operating between 1984 and 1991, with the exception of sole-provider hospitals. Data for the study are obtained from four sources: the AHA Annual Surveys of Hospitals, the HCFA Cost Reports, the Area Resource File, and a hospital address file constructed by Geographic Inc. DATA COLLECTION AND ANALYSIS: Variables are merged to construct pooled, time-series observations for study hospitals. Hospital closure is specified as a function of hospital market position, market level competition, and control variables. Discrete-time logistic regressions are used to test hypotheses. PRINCIPAL FINDINGS: Rural hospitals operating in markets with higher density had higher risk of closure. Rural hospitals that differentiated from others in the market on the basis of geographic distance, basic services, and high-tech services had lower risks of closure. Effects of market density on closure disappeared when market position was included in the model, indicating that differentiation in markets should be taken into account when evaluating the effects of competition on rural hospital closure. CONCLUSIONS: Our findings suggest that rural hospitals can reduce competitive pressures through differentiation and that accurate measures of competition in geographically defined market areas are critical for understanding competitive dynamics among rural hospitals.     

Reforming the hospital service structure to improve efficiency: urban hospital specialization

The objective of this study is to explain the relationship between the case-mix specialization index and efficiency of inpatient hospital care services. Hospital specialization was measured using the information theory index constructed from diagnosis-related group numbers of hospitals in Seoul, Korea, in 2004. Hospital performance was measured by technical efficiency scores computed by data envelopment analysis for 2004. Multiple regression analysis models were applied to identify the internal and external factors that affected the extent of hospital specialization status as well as the efficiency of hospitals. The data envelopment analysis showed that input variables such as the number of beds, doctors and nurses were related to hospital efficiency. Hospitals had different levels of specialization in patient services, and more specialized hospitals were more likely to be efficient (odds ratio=25.95). Internal characteristics of providers had more significant effects on the extent of specialization than market conditions. These findings help to explain the relationship among hospitals, specialization, market conditions and provider performance. The study results related to the rearrangement of hospital services in a city. Further study including hospitals from other regions will increase the generalizability of results, and policy makers can use the information in making policy for the specialized hospital industry in Korea.     

Substituting inpatient for outpatient care: what is the impact on hospital costs and efficiency?

Substitution of inpatient for outpatient care is seen as a means to increase patient throughput and control costs. The purpose of this study was to assess the impact of increased outpatient care on hospital costs and efficiency using Finnish specialty-level data from years 2003–2006 to which we applied stochastic frontier analysis. The results reveal that outpatient services have a smaller impact on total costs than inpatient services. At the same time, increased outpatient activity appears to have an adverse effect on estimated cost efficiency. This counterintuitive finding is probably due to the low weight given to outpatient activities by the Diagnosis Related Groups (DRG) system. A common weighting for inpatient and outpatient services is required in order to assess accurately the impact of outpatient care on efficiency.     

Assessment of the introduction of DRG-based reimbursement in Switzerland: Evidence on the short-term effects on length of stay compliance in university hospitals

The implementation of a nationwide diagnosis-related groups (DRG) reimbursement system in 2012 marked an important step in increasing the transparency and efficiency of hospital services in Switzerland. However, no clear evidence exists to date on the response of hospitals to the introduction of SwissDRG. Using administrative data on inpatient stays in Swiss university hospitals and the length of stay compliance (LOSC) as a measure of hospital performance, we find a significant short-term reduction in LOSC for hospitals that experienced a change from retrospective per diem to prospective DRG reimbursement, compared to hospitals with a prospective payment system already before 2012. LOSC can be interpreted as a performance indicator because it compares the actual length of stay with a benchmark value, taken from the yearly DRG catalogue. The reduction in LOSC implies that hospitals in the treatment group on average had an increase in LOS relative to the benchmark compared to the control hospitals. This may be interpreted as a negative effect of SwissDRG on hospital performance, at least in the short-run, and we provide supporting evidence that hospitals that worked under DRG already before adapted more quickly and efficiently.     

Socioeconomic inequalities in health care utilisation in Norway: the population-based HUNT3 survey

ABSTRACT: BACKGROUND: In this study we investigated the distribution of self-reported health care utilisation by education and household income in a county population in Norway, in a universal public health care system based on ideals of equal access for all according to need, and not according to wealth. METHODS: The study included 24,147 women and 20,608 men aged 20 years and above in the third Nord-Trondelag Health Survey (HUNT 3) of 2006--2008. Income-related horizontal inequity was estimated through concentration indexes, and inequity by both education and income was estimated as risk ratios through conventional regression. RESULTS: We found no overall pro-rich or pro-educated socioeconomic gradient in needs-adjusted utilisation of general practitioner or inpatient care. However, we found overall pro-rich and pro-educated inequity in utilisation of both private medical specialists and hospital outpatient care. For these services there were large differences in levels of inequity between younger and older men and women. CONCLUSION: In contrast with recent studies from Norway, we found pro-rich and pro-educated social inequalities in utilisation of hospital outpatient services and not only private medical specialists. Utilisation of general practitioner and inpatient services, which have low access threshold or are free of charge, we found to be equitable.     

Equity of use of inpatient services by the two communities in Northern Ireland

OBJECTIVE: There is concern about whether public services in Northern Ireland are equitably targeted across the religious divide. This study investigates whether use of acute hospital inpatient services differs by religious denomination, after adjusting for supply and for identified demographic, morbidity and socio-economic determinants of need for such services. METHODS: Hospital utilisation at small area level was modelled against a wide range of potential health and socioeconomic factors. Spatial interactive modelling was used to estimate the effect of supply of hospital beds and other facilities on hospital utilisation. Two-stage weighted least-squares regression was used to model utilisation against need and supply. RESULTS: There was a clear positive relationship between the proportion of Roman Catholics in a ward and both need for and utilisation of inpatient services. The higher levels of relative utilisation in wards with a greater proportion of Catholics persisted after controlling for needs but not when supply variables were also entered in the regression equation. The surviving needs drivers were: uptake levels of 'income maintenance' benefits, all-ages standardised mortality ratio, low birth weight and elderly people living alone. Most of these indicators of need are positively correlated with proportion of Catholics. CONCLUSIONS: When both need and supply factors are taken into account, there appears to be no significant effect of religion on inpatient hospital use in Northern Ireland. Efforts to ensure socio-economic equity between the two communities should focus on ensuring that hospital rationalisation does not lead to disadvantage and on reducing socio-economic differentials between the Catholic and Protestant communities.     

The consumer welfare implications of the hospital ownership mix in the US: an exploratory study

This paper offers an empirical test concerning how hospital ownership mix affects consumer welfare in the US. The test compares the market benefits and costs resulting from an increased presence of nonprofit hospitals by observing empirically how the nonprofit market share impacts hospital care utilization at the margin. The empirical results suggest that too many not-for-profit and public hospitals exist in the inpatient care segment of the typical hospital services industry of the US. In contrast, the empirical findings indicate that too many for-profit hospitals operate in the outpatient care portion of the hospital services industry. The policy implication is that more quality of care per dollar might be obtained by promoting increased for-profit activity to inpatient care and more nonprofit activity to outpatient care in some market areas. This conclusion, however, is tempered with several caveats. We discuss these and also make recommendations for further research.