Hospital ownership and performance: evidence from stroke and cardiac treatment in Taiwan

This paper compares program expenditure and treatment quality of stroke and cardiac patients between 1997 and 2000 across hospitals of various ownership types in Taiwan. Because Taiwan implemented national health insurance in 1995, the analysis is immune from problems arising from the complex setting of the U.S. health care market, such as segmentation of insurance status or multiple payers. Because patients may select admitted hospitals based on their observed and unobserved characteristics, we employ instrument variable (IV) estimation to account for the endogeneity of ownership status. Results of IV estimation find that patients admitted to non-profit hospitals receive better quality care, either measured by 1- or 12-month mortality rates. In terms of treatment expenditure, our results indicate no difference between non-profits and for-profits index admission expenditures, and at most 10% higher long-term expenditure for patients admitted to non-profits than to for-profits.     

Hospital ownership and preventable adverse events.

To determine whether hospital ownership was associated with preventable adverse events, the authors reviewed the medical records of a random sample of 15,000 hospitalizations in Utah and Colorado in 1992. Hospitals were categorized as nonprofit, for-profit, major teaching government (e.g., county, state ownership), and minor or nonteaching government. Multivariate analyses adjusting for other patient and hospital characteristics found that, when compared with patients in nonprofit hospitals, patients in minor or nonteaching government hospitals were more likely to suffer a preventable adverse event of any type (odds ratio (OR), 2.46; 95 percent confidence interval (95% CI), 1.45 to 4.20); preventable operative adverse events (OR, 4.85; 95% CI, 2.44 to 9.62); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.27; 95% CI, 1.48 to 12.31). Patients in for-profit hospitals were also more likely to suffer preventable adverse events of any type (OR, 1.57; 95% CI, 1.03 to 2.38); preventable operative adverse events (OR, 2.63; 95% CI, 1.42 to 4.87); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.15; 95% CI, 1.84 to 9.34). Patients in major teaching government hospitals were less likely to suffer preventable adverse drug events (OR, 0.38; 95% CI, 0.16 to 0.89).     

Hospital ownership, reimbursement systems and mortality rates

This paper analyses the effect of ownership and system of reimbursement on mortality rates. From the statistical results we could conclude that the incentive created by fee-for-service reimbursement yields a four-point reduction in the mortality rate. However, this ranking of hospital quality is completely dependent on the characteristics and illness severity of patients. To take this difficulty into account, we use an innovative duration model applied to panel data: a duration model with both patient and hospital unobserved heterogeneity. No distributional assumptions are made regarding the latter. By this way, we control the fact that patients admitted to the private sector can be different in terms of disease severity from patients admitted to the public sector.The capacity to perform innovative procedures has more effect on the mortality than the system of reimbursement and/or ownership. As such, private sector hospitals that perform more innovative procedures provide a better quality of care, measured by the probability of dying. Nevertheless, heterogeneity within hospitals is greater in for-profit hospitals than in other types of hospital. This suggests that, by choosing a for-profit hospital, patients have on average a lower instantaneous probability of dying but are less sure about the quality of the hospital.     

Strategic options for hospitals based on ownership type

Strategic planning for hospitals is difficult in this era of healthcare reform. This article offers strategy options based on an analysis of the strengths, weaknesses, opportunities, and threats of three types of hospitals.     

The impact of ownership type on nursing home outcomes

This paper examines the sorting of residents between for-profit and nonprofit nursing homes and the health outcomes of those residents conditional on ownership type. Using data from the 1987 National Medical Expenditure Survey, we find evidence of systematic sorting of residents by ownership type, and significant effects of ownership type on outcomes. These results are broadly consistent with the hypothesis that for-profit and nonprofit homes exploit their informational advantages to differing extents in a market characterized by asymmetric information. © 1998 John Wiley & Sons, Ltd.     

医院所有制与效率：以德国为关注重点的研究回顾

德国医院市场在过去20年里进行了一揽子医疗改革,特别是在2004年引进了疾病诊断相关分组——以期提高医院效率。本文旨在回顾近期就比较德国公立医院、私立非营利医院和私立营利医院效率所开展的研究。尽管研究结果错综复杂,但结合其他国家,特别是美国的研究证据,德国方面的研究结果表明:与公立医院相比,私立医院(私立非营利和私立营利医院)的运营效率并不一定就高。由于私立营利医院通常都会被认为是最有效率的所有制形式,因此本研究结果对很多决策者来说也许有些意外。     

Hospital ownership and efficiency: a review of studies with particular focus on Germany

The German hospital market has been subject over the past two decades to a variety of healthcare reforms. Particularly the introduction of diagnosis-related groups (DRGs) in 2004 aimed to increase efficiency of hospitals. The objective of the paper is to review recent studies comparing the efficiency of German public, private non-profit and private for-profit hospitals. The results of the studies are quite mixed. However, in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., private non-profit and private for-profit) is not necessarily associated with higher efficiency compared to public ownership. This may be a surprising result to many policy makers as private for-profit hospitals are often perceived the most efficient ownership type by the public.     

Hospital ownership and medical services: Market mix, spillover effects, and nonprofit objectives

Hospitals operate in markets with varied demographic, competitive, and ownership characteristics, yet research on ownership tends to examine hospitals in isolation. Here we examine three hospital ownership types – nonprofit, for-profit, and government – and their spillover effects. We estimate the effects of for-profit market share in two ways, on the provision of medical services and on operating margins at the three types of hospitals. We find that nonprofit hospitals’ medical service provision systematically varies by market mix. We find no significant effect of market mix on the operating margins of nonprofit hospitals, but find that for-profit hospitals have higher margins in markets with more for-profits. These results fit best with theories in which hospitals maximize their own output.     

Nursing home cost and ownership type: evidence of interaction effects.

Due to steadily increasing public expenditures for nursing home care, much research has focused on factors that influence nursing home costs, especially for Medicaid patients. Nursing home cost function studies have typically used a number of predictor variables in a multiple regression analysis to determine the effect of these variables on operating cost. Although several authors have suggested that nursing home ownership types have different goal orientations, not necessarily based on economic factors, little attention has been paid to this issue in empirical research. In this study, data from 150 Virginia nursing homes were used in multiple regression analysis to examine factors accounting for nursing home operating costs. The context of the study was the Virginia Medicaid reimbursement system, which has intermediate care and skilled nursing facility (ICF and SNF) facility-specific per diem rates, set according to facility cost histories. The analysis revealed interaction effects between ownership and other predictor variables (e.g., percentage Medicaid residents, case mix, and region), with predictor variables having different effects on cost depending on ownership type. Conclusions are drawn about the goal orientations and behavior of chain-operated, individual for-profit, and public and nonprofit facilities. The implications of these findings for long-term care reimbursement policies are discussed.     

People with diabetes mellitus: their care and treatment choices

Study based on qualitative research, from an interpretative perspective. Its objective was to understand the therapeutic itinerary of people with Diabetes Mellitus who search for different care and treatments within the different subsystems of health care. The data was collected through in-depth interviews and focus groups. As a result of the data analysis therapeutic modalities were identified, the evaluation of the care process and health treatment and the therapeutic journey in the three subsystems. The person with Diabetes Mellitus needs to reevaluate their process of living. Thus, the person circulates through various therapeutic modalities until they perceive that (or those) which are most convenient for them. This also applies to how said care or treatment becomes integrated into their day-to-day.     

Childhood diarrhoea in a district in northeast Thailand: incidence and treatment choices

Diarrhoeal disease is a major public health problem in Thailand. We collected information on childhood diarrhoea from a district in northeast Thailand, using various approaches which focus on both consumers and providers. The overall incidence of diarrhoea in the study area was 2.1 episodes per child per 12 months, with children under two years of age having a higher rate at 3.0 episodes per child per 12 months. Many episodes were not recognized as diarrhoeal episodes by caregivers, and treatment was sought in just over half of all episodes. Although children received an average of 2.4 items of medicine per episode, there was relatively low use of oral rehydration solutions. This study highlights the importance of assessing local beliefs when collecting data on diarrhoeal diseases in children, and the importance of continuing efforts to improve public health education on the management of diarrhoeal diseases.     

Patients' choices and perceptions after an invitation to participate in treatment decisions.

Previous search indicates that treatment outcomes may be improved if patients perceive greater control over their treatment, but the practical implications of encouraging patients to take more control have not been investigated. The present study investigated responses of 143 patients in a cardiovascular risk management clinic to an invitation to make a decision about their treatment. Subjects' choices of the target behaviour for their behaviour-change treatment were highly predictable from their state of health, reasons for coming to the clinic, what behaviours they were told they were at risk from, and contacts with health workers. The degree of control that subjects reported they had over the decision varied considerably, being negatively related to blood pressure and positively related to the degree of control that subjects believed they had over their health in general. Issues such as time-demands, the practitioner's job satisfaction, and ethical implications of patient participation are discussed.     

End-of-life medical treatment choices: do survival chances and out-of-pocket costs matter?

BACKGROUND: Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the public's opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion. OBJECTIVES: To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs. METHODS: Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s. RESULTS: Respondents were more likely to recommend treatment when it was financed by Medicare than by the patient's own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects. CONCLUSIONS: Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice.     

Influence of surgical and treatment choices on the cost of breast cancer care

We obtained medical claim files covering a period of 1 year prior to breast cancer diagnosis and the year following diagnosis for 204 women and estimated the cost of their treatment. We used log-linear regression controlling for age, comorbidity, physical functioning, and disease stage. To retransform the mean costs, we estimated separate smearing factors for surgical and adjuvant care types. The adjusted mean costs for breast cancer care ranged from $16,226 to $39,305 depending on the treatment provided with mastectomy being the least expensive option. Breast-conserving surgery (BCS) was more expensive because most women have multiple surgeries after the initial BCS and require adjuvant care. If the first surgery was a mastectomy, medical care use tends to return to precancer spending levels within a few months. Over one-half of the women in this study had multiple surgeries following diagnosis, leading to substantial costs and unknown morbidity.     

The effects of insurance mandates on choices and outcomes in infertility treatment markets

For the 10% to 15% of American married couples who experience reproductive problems, in vitro fertilization (IVF) is the leading technologically advanced treatment procedure. However, IVF's expense may prevent many couples from receiving treatment, and those who are treated may take an overly aggressive approach to reduce the probability of failure. Aggressive treatment, which occurs through an increase in the number of embryos transferred during IVF, can lead to medically dangerous multiple births. We evaluated the principle policy proposal-insurance mandates-for improving IVF access and outcomes. We used data from US markets during 1995-2003 to show that broad insurance mandates for IVF result in not only large increases in treatment access but also significantly less aggressive treatment. More limited insurance mandates, which may apply to a subset of insurers or provide weaker guidelines for insurer behavior, generally have little effect on IVF markets.