Public sector hospital competition improved quality and productivity in the English NHS according to a study of reforms introduced in 2006. The key findings were:
1. Hospitals located in more competitive areas pre-reform saw a relative 6.7% reduction in AMI mortality post-reform, saving approximately 300 lives per year.
2. Competition between public hospitals improved productivity, with each additional hospital associated with a 4-9% increase in lean production.
3. Entrance of private providers did not help or harm public hospital productivity but led to risk selection, leaving public hospitals with older, less wealthy patients and excess costs of £700,000 per hospital.
This document summarizes a presentation on provider competition in the NHS. It discusses the theory and evidence on competition, outlines NHS policy history on competition, and assesses the feasibility of competition across different health services and markets. Key points include that competition can reduce costs and waiting times but also quality if not monitored, and the appropriateness of competition depends on market characteristics like demand stability and ability to assess quality.
The document discusses dispensing practices in Scotland compared to community pharmacies, noting that while dispensing practices serve older, more rural populations and dispense more items that are cheaper on average, differences in fees and VAT reimbursement make their total costs higher per patient currently. It also analyzes the significant negative impact of Scotland's Category M drug pricing changes on dispensing practice incomes. Potential options to address perceived cost differences are discussed, including adopting formularies or standards while maintaining rural access to services.
Higher income is associated with changes in long-term care utilization patterns among the elderly. Using a "benefits notch" in Social Security income as an instrumental variable, the study finds that a $1,000 increase in annual household income:
1) Decreases the likelihood of nursing home use by 2.9 percentage points;
2) Increases the likelihood of paid home care use by 2.3 percentage points; and
3) Has no significant effect on informal unpaid care.
The findings suggest higher income leads to substitution away from nursing home care towards paid home care utilization.
The document summarizes research on understanding overeating and obesity from a behavioral economics perspective. It discusses how the brain has both a deliberative, rational system and an affective, emotional system that can lead to deviations from optimal food intake and weight. A dual decision model is presented where food consumption and weight exceed utility-maximizing levels due to interactions between these two systems. Predictions of the model related to disproportionate weight growth in heavier individuals, common weight mistakes and dieting attempts, unintended weight gains, and greater consumption of engineered foods by obese individuals are evaluated using U.S. health survey data.
This document discusses a research project examining variation in treatment of pelvic organ prolapse at the physician level. The project analyzed over 168,000 cases of pelvic organ prolapse surgery from 1992-2010 in Florida and New York to determine predictors of physicians adhering to guidelines recommending pelvic floor repair (pexia). The analysis found pexia rates increased over time but did not reach 100% compliance, and physicians who treated more prolapse cases per year were more likely to perform pexia. The results suggest physician specialization may impact treatment, though significant variation remains. Next steps include focusing on the impact of physician training and exploring related topics like mesh usage.
This document discusses how new incentives like meaningful use payments for electronic health records and payment reform, combined with increasing availability of health data through initiatives like Blue Button and HealthData.gov, are fueling innovation at the intersection of health, data, and technology. It provides examples of startups and applications emerging to help consumers, providers, employers, and communities improve health using this newly available data. The goal is to create an open "ecosystem of innovation" where health data drives the creation of new products and services.
This document discusses how personalized medicine could help save the healthcare system by tailoring treatment to individuals based on their underlying risk profiles. It provides examples from studies showing how risk stratification can lead to more efficient and effective care by targeting high-risk groups and avoiding overtreatment of low-risk groups. The document argues current guidelines often define optimal care based on average results from clinical trials without considering individual risk factors and patient preferences.
This document summarizes a presentation on provider competition in the NHS. It discusses the theory and evidence on competition, outlines NHS policy history on competition, and assesses the feasibility of competition across different health services and markets. Key points include that competition can reduce costs and waiting times but also quality if not monitored, and the appropriateness of competition depends on market characteristics like demand stability and ability to assess quality.
The document discusses dispensing practices in Scotland compared to community pharmacies, noting that while dispensing practices serve older, more rural populations and dispense more items that are cheaper on average, differences in fees and VAT reimbursement make their total costs higher per patient currently. It also analyzes the significant negative impact of Scotland's Category M drug pricing changes on dispensing practice incomes. Potential options to address perceived cost differences are discussed, including adopting formularies or standards while maintaining rural access to services.
Higher income is associated with changes in long-term care utilization patterns among the elderly. Using a "benefits notch" in Social Security income as an instrumental variable, the study finds that a $1,000 increase in annual household income:
1) Decreases the likelihood of nursing home use by 2.9 percentage points;
2) Increases the likelihood of paid home care use by 2.3 percentage points; and
3) Has no significant effect on informal unpaid care.
The findings suggest higher income leads to substitution away from nursing home care towards paid home care utilization.
The document summarizes research on understanding overeating and obesity from a behavioral economics perspective. It discusses how the brain has both a deliberative, rational system and an affective, emotional system that can lead to deviations from optimal food intake and weight. A dual decision model is presented where food consumption and weight exceed utility-maximizing levels due to interactions between these two systems. Predictions of the model related to disproportionate weight growth in heavier individuals, common weight mistakes and dieting attempts, unintended weight gains, and greater consumption of engineered foods by obese individuals are evaluated using U.S. health survey data.
This document discusses a research project examining variation in treatment of pelvic organ prolapse at the physician level. The project analyzed over 168,000 cases of pelvic organ prolapse surgery from 1992-2010 in Florida and New York to determine predictors of physicians adhering to guidelines recommending pelvic floor repair (pexia). The analysis found pexia rates increased over time but did not reach 100% compliance, and physicians who treated more prolapse cases per year were more likely to perform pexia. The results suggest physician specialization may impact treatment, though significant variation remains. Next steps include focusing on the impact of physician training and exploring related topics like mesh usage.
This document discusses how new incentives like meaningful use payments for electronic health records and payment reform, combined with increasing availability of health data through initiatives like Blue Button and HealthData.gov, are fueling innovation at the intersection of health, data, and technology. It provides examples of startups and applications emerging to help consumers, providers, employers, and communities improve health using this newly available data. The goal is to create an open "ecosystem of innovation" where health data drives the creation of new products and services.
This document discusses how personalized medicine could help save the healthcare system by tailoring treatment to individuals based on their underlying risk profiles. It provides examples from studies showing how risk stratification can lead to more efficient and effective care by targeting high-risk groups and avoiding overtreatment of low-risk groups. The document argues current guidelines often define optimal care based on average results from clinical trials without considering individual risk factors and patient preferences.
This document discusses health care reform and the 2008 election. It summarizes the health reform plans of Obama and McCain, noting their strengths and weaknesses. It outlines the political challenges to enacting reform and lessons that should be learned from past failures. While the problems are worse and some see signs of bipartisanship, major reforms have been proposed but not enacted before. Enacting comprehensive reform will be difficult despite Democratic congressional majorities.
This document summarizes a study on how endogenous cost-effectiveness analysis impacts health care technology adoption. It finds that when prices are set based on cost-effectiveness thresholds, rather than costs alone, it can lead technologies with higher costs but more demand to be adopted over those with lower costs. This is because demand allows prices and markups to exceed costs. The study uses data from the National Institute for Health and Clinical Excellence in the UK from 1999-2005 to show some evidence of reversals in adoption decisions compared to what cost-effectiveness alone would predict. It concludes more research is needed to fully understand the impact of endogenous cost-effectiveness on technology adoption decisions.
This document discusses using premium policies to efficiently assign Medicare beneficiaries to traditional Medicare or Medicare Advantage plans. It argues that a single premium cannot achieve efficiency and that an income-based premium is needed. The key points are:
1) A single premium for all beneficiaries cannot achieve an efficient assignment between traditional Medicare and Medicare Advantage plans.
2) An income-based premium, where higher-income beneficiaries pay more to join traditional Medicare, can implement any efficient allocation.
3) Allowing Medicare Advantage plans to set their own premiums interferes with using premiums to efficiently assign beneficiaries.
This document outlines a research project on food access in Philadelphia. The project will use historical ethnography and qualitative methods to examine: (1) the historical transformation of Philadelphia's fresh produce markets; (2) the morality of food production and distribution; and (3) efforts to reconnect farms and cities through alternative markets. Specific research questions focus on the types of markets historically created for produce and changes in grocery stores over time. Newspaper archives will be analyzed to understand cultural representations of concepts like "farmer's markets" and "fresh food." Preliminary results found an increase in newspaper articles about farmer's markets over time and that their stories were part of narratives around industrialization and urbanization. The research aims to better understand "food
This study aimed to understand prostate cancer patients' attitudes toward out-of-pocket healthcare costs. Semi-structured interviews were conducted with 34 prostate cancer patients. The majority had health insurance and did not feel burdened by costs. However, 3 patients with less education and income reported financial difficulties. Most patients felt that health was more important than cost and their treatment choice was not affected by prices. However, patients without insurance may feel differently. The study provides insight into patients' perspectives on healthcare costs.
- The document summarizes Brian Elbel's research on the influence of calorie labeling on fast food purchases in New York City and Newark.
- A field study found that calorie labeling in NYC did not significantly change the number of calories purchased by adults or children. About a quarter of adults noticed the labels but there was no difference in calories purchased.
- Knowledge of recommended daily calorie amounts was low both before and after labeling. The study suggests that calorie labeling may have limited influence if consumers are unaware of recommended calorie guidelines.
The document summarizes Earl Steinberg's presentation about care management at Geisinger. It provides an overview of Geisinger, highlights its key attributes that enable innovation, and describes some of its notable programs and results. It also outlines Geisinger's plans to open a new Center for Health Care Transformation and efforts to disseminate its approaches.
The document summarizes a student's summer research project studying patient perspectives on teamwork in the emergency department. The student administered exit surveys to emergency department patients to assess how perceptions of provider teamwork related to patient satisfaction, confidence in providers, and likelihood of following treatment recommendations. The student hypothesized that patients would be less likely to endorse clear team roles but more likely to perceive providers as enjoying their work and sharing treatment goals. The student also hypothesized that more positive perceptions of teamwork would correlate with higher patient ratings in the areas studied. Preliminary results did not support the first hypothesis but supported associations between teamwork perceptions and patient outcomes as outlined in the second hypothesis.
This document provides an overview of two studies being presented at an LDI symposium. The first study analyzes video recordings of clinician interactions with patients, nurses and families in the surgical intensive care unit. It aims to evaluate the extent of clinician involvement and how it may impact outcomes. The second study seeks to identify characteristics of effective ad hoc trauma resuscitation teams and how team functioning affects patient outcomes. It will survey team members and analyze responses to identify qualities of high performing teams with the goal of developing training to improve collaboration and outcomes.
Len Nichols discusses communicating with Americans about health reform and cost containment. He finds that [1] polling shows Americans want lower costs but oppose specific cost-cutting policies, [2] politicians exploit this by misrepresenting reform, and [3] rebuilding trust and finding bipartisan agreement on the true costs is key to effective communication. Nichols advocates learning from the Constitutional Convention by listening to opponents and debating policies fairly based on their actual implications.
The document summarizes a presentation on value-based insurance design given at the University of Pennsylvania. It discusses how increasing cost-sharing reduces utilization of high-value health services and medications, leading to worse health outcomes. It presents a study that reduced copays for diabetes medications for University of Michigan employees, finding increased medication use and adherence, with the goal of improving health while containing costs. The presentation argues for insurance designs that incentivize use of services with clear health benefits.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document provides an industry analysis of Apollo Hospitals, a leading private healthcare provider in India. It discusses the healthcare industry in India and key players. Apollo Hospitals was established in 1983 and today has over 7500 beds across 43 hospitals in India and overseas. It provides a wide range of healthcare services including hospitals, clinics, pharmacies, insurance, and education and aims to make India a global healthcare destination. The document outlines Apollo's business units and services.
The introduction of competition into the English NHS appears to have had some positive effects according to evidence from the Health Reform Evaluation Programme. Competition was associated with improved clinical outcomes and shorter hospital stays. Payment by results reduced lengths of stay and increased day surgery rates more in foundation trusts. However, patient choice directly affected only a small percentage of patients and barriers limited new provider entry. Overall, the evidence suggests the NHS market reforms have had some success in improving quality but implementation has been variable.
Dr Jennifer Dixon: Competition between providersNuffield Trust
Competition in healthcare provision in England has increased through policies introducing market mechanisms since 2002. While independent sector activity makes up a small percentage of overall NHS care, research finds competition is associated with reduced mortality, especially for heart attacks. Competition may also reduce waiting times. Primary and community care is seeing more competitive tendering, with many contracts awarded to independent providers. Further evidence is still needed on the impacts of competition and potential mergers on quality, costs and regulation of different provider models.
Anita Charlesworth: The economics of integrationNuffield Trust
The document discusses regulatory issues related to integration in healthcare systems. It summarizes Monitor's new role as an economic regulator under the Health and Social Care Bill, including licensing providers, regulating prices, and promoting competition. It also discusses the empirical evidence around whether healthcare exhibits natural monopoly characteristics. While some studies find volume-outcome relationships and potential economies of scale, other research shows costs leveling off or increasing with scale beyond a relatively small threshold. The impact of mergers on costs and prices is mixed in the evidence.
Prof. Carol Propperin esitys VATT-päivässä 1.11.2016.
Professori Carol Propper on taloustieteen professori Imperial College London -yliopistossa Lontoossa, Iso-Britanniassa. Professori Propperin tutkimus keskittyy kannustin- ja kilpailukysymyksiin terveydenhuoltomarkkinoilla sekä yleisemmin kannustimien suunnitteluun ja vaikutuksiin julkisella sektorilla sekä julkisen ja yksityisen markkinoiden rajapinnalla. Hän on kuuluisa erityisesti tutkimuksistaan, joissa on tarkasteltu kilpailun ja valinnanvapautta lisäävien uudistusten vaikutuksia terveydenhuollon toimintaan Iso-Britanniassa.
This document discusses health technology assessment (HTA) and commissioning in the English NHS, with a focus on general practitioners (GPs). It provides background on HTA, which evaluates the clinical effectiveness and cost-effectiveness of health interventions. It also discusses key elements of the 2010 NHS reform plan and the history of GP commissioning in England since the 1990s, including GP fundholding schemes that gave GPs budgets to purchase some services. Evaluation found GPs were able to improve primary care and develop alternatives to hospital care, but faced challenges shifting resources from hospitals.
This document summarizes evidence on incentivizing competition in public services like healthcare. It finds that separating healthcare provision from funding through insurance schemes can introduce competition but consolidation limits its effects. Prices set prospectively for hospitals may increase quality and activity. Limited evidence shows negotiated prices between insurers and providers can decrease quality. More autonomy and control over surpluses for providers is associated with better outcomes but regulations often erode such autonomy. Competition among family doctors with limited cost sharing can increase satisfaction and quality to a small degree. However, strong consolidation trends and heavy regulation limit meaningful competition in many European healthcare systems.
1) The document summarizes recent reforms to the English National Health Service (NHS) proposed by the UK coalition government.
2) Key aspects of the reforms include transferring around 70% of the NHS budget to groups of general practitioners (GPs), increasing hospital autonomy and competition, and expanding patient choice.
3) The reforms aim to reduce central control over the NHS and introduce more market-based incentives, but also face significant implementation challenges and risks of disruption.
How diagnostics can drive efficiency within the NHSWalt Whitman
This document summarizes a presentation on how diagnostics can drive efficiency within the NHS. It notes that demand for diagnostic tests and waiting lists have increased in recent years without equivalent funding growth. Wide variation exists in diagnostic quality and access across regions. The presentation calls for diagnostics to be optimized by reducing unwarranted variation, improving data sharing and digital infrastructure, addressing capacity issues, and incentivizing efficiency. Recent NHS data collection and modeling identified over 30 million fewer tests, £33.6 million in cost savings, and opportunities to standardize practices and reduce costs in imaging services.
Tariff setting in Dutch Healthcare system, Johan van ManenOliver O'Connor
This document discusses health care reform and tariff setting in the Netherlands. It outlines two models used to calculate tariffs. Model I calculates average costs per diagnostic treatment combination (DBC) procedure based on a sample of hospitals, while Model II calculates total costs per DBC for each hospital. The document also describes how the proportion of regulated versus negotiable hospital costs and physician fees has changed over time as the system transitioned from centralized regulation to more market-based negotiations between insurers and providers.
This document discusses health care reform and the 2008 election. It summarizes the health reform plans of Obama and McCain, noting their strengths and weaknesses. It outlines the political challenges to enacting reform and lessons that should be learned from past failures. While the problems are worse and some see signs of bipartisanship, major reforms have been proposed but not enacted before. Enacting comprehensive reform will be difficult despite Democratic congressional majorities.
This document summarizes a study on how endogenous cost-effectiveness analysis impacts health care technology adoption. It finds that when prices are set based on cost-effectiveness thresholds, rather than costs alone, it can lead technologies with higher costs but more demand to be adopted over those with lower costs. This is because demand allows prices and markups to exceed costs. The study uses data from the National Institute for Health and Clinical Excellence in the UK from 1999-2005 to show some evidence of reversals in adoption decisions compared to what cost-effectiveness alone would predict. It concludes more research is needed to fully understand the impact of endogenous cost-effectiveness on technology adoption decisions.
This document discusses using premium policies to efficiently assign Medicare beneficiaries to traditional Medicare or Medicare Advantage plans. It argues that a single premium cannot achieve efficiency and that an income-based premium is needed. The key points are:
1) A single premium for all beneficiaries cannot achieve an efficient assignment between traditional Medicare and Medicare Advantage plans.
2) An income-based premium, where higher-income beneficiaries pay more to join traditional Medicare, can implement any efficient allocation.
3) Allowing Medicare Advantage plans to set their own premiums interferes with using premiums to efficiently assign beneficiaries.
This document outlines a research project on food access in Philadelphia. The project will use historical ethnography and qualitative methods to examine: (1) the historical transformation of Philadelphia's fresh produce markets; (2) the morality of food production and distribution; and (3) efforts to reconnect farms and cities through alternative markets. Specific research questions focus on the types of markets historically created for produce and changes in grocery stores over time. Newspaper archives will be analyzed to understand cultural representations of concepts like "farmer's markets" and "fresh food." Preliminary results found an increase in newspaper articles about farmer's markets over time and that their stories were part of narratives around industrialization and urbanization. The research aims to better understand "food
This study aimed to understand prostate cancer patients' attitudes toward out-of-pocket healthcare costs. Semi-structured interviews were conducted with 34 prostate cancer patients. The majority had health insurance and did not feel burdened by costs. However, 3 patients with less education and income reported financial difficulties. Most patients felt that health was more important than cost and their treatment choice was not affected by prices. However, patients without insurance may feel differently. The study provides insight into patients' perspectives on healthcare costs.
- The document summarizes Brian Elbel's research on the influence of calorie labeling on fast food purchases in New York City and Newark.
- A field study found that calorie labeling in NYC did not significantly change the number of calories purchased by adults or children. About a quarter of adults noticed the labels but there was no difference in calories purchased.
- Knowledge of recommended daily calorie amounts was low both before and after labeling. The study suggests that calorie labeling may have limited influence if consumers are unaware of recommended calorie guidelines.
The document summarizes Earl Steinberg's presentation about care management at Geisinger. It provides an overview of Geisinger, highlights its key attributes that enable innovation, and describes some of its notable programs and results. It also outlines Geisinger's plans to open a new Center for Health Care Transformation and efforts to disseminate its approaches.
The document summarizes a student's summer research project studying patient perspectives on teamwork in the emergency department. The student administered exit surveys to emergency department patients to assess how perceptions of provider teamwork related to patient satisfaction, confidence in providers, and likelihood of following treatment recommendations. The student hypothesized that patients would be less likely to endorse clear team roles but more likely to perceive providers as enjoying their work and sharing treatment goals. The student also hypothesized that more positive perceptions of teamwork would correlate with higher patient ratings in the areas studied. Preliminary results did not support the first hypothesis but supported associations between teamwork perceptions and patient outcomes as outlined in the second hypothesis.
This document provides an overview of two studies being presented at an LDI symposium. The first study analyzes video recordings of clinician interactions with patients, nurses and families in the surgical intensive care unit. It aims to evaluate the extent of clinician involvement and how it may impact outcomes. The second study seeks to identify characteristics of effective ad hoc trauma resuscitation teams and how team functioning affects patient outcomes. It will survey team members and analyze responses to identify qualities of high performing teams with the goal of developing training to improve collaboration and outcomes.
Len Nichols discusses communicating with Americans about health reform and cost containment. He finds that [1] polling shows Americans want lower costs but oppose specific cost-cutting policies, [2] politicians exploit this by misrepresenting reform, and [3] rebuilding trust and finding bipartisan agreement on the true costs is key to effective communication. Nichols advocates learning from the Constitutional Convention by listening to opponents and debating policies fairly based on their actual implications.
The document summarizes a presentation on value-based insurance design given at the University of Pennsylvania. It discusses how increasing cost-sharing reduces utilization of high-value health services and medications, leading to worse health outcomes. It presents a study that reduced copays for diabetes medications for University of Michigan employees, finding increased medication use and adherence, with the goal of improving health while containing costs. The presentation argues for insurance designs that incentivize use of services with clear health benefits.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document provides an industry analysis of Apollo Hospitals, a leading private healthcare provider in India. It discusses the healthcare industry in India and key players. Apollo Hospitals was established in 1983 and today has over 7500 beds across 43 hospitals in India and overseas. It provides a wide range of healthcare services including hospitals, clinics, pharmacies, insurance, and education and aims to make India a global healthcare destination. The document outlines Apollo's business units and services.
The introduction of competition into the English NHS appears to have had some positive effects according to evidence from the Health Reform Evaluation Programme. Competition was associated with improved clinical outcomes and shorter hospital stays. Payment by results reduced lengths of stay and increased day surgery rates more in foundation trusts. However, patient choice directly affected only a small percentage of patients and barriers limited new provider entry. Overall, the evidence suggests the NHS market reforms have had some success in improving quality but implementation has been variable.
Dr Jennifer Dixon: Competition between providersNuffield Trust
Competition in healthcare provision in England has increased through policies introducing market mechanisms since 2002. While independent sector activity makes up a small percentage of overall NHS care, research finds competition is associated with reduced mortality, especially for heart attacks. Competition may also reduce waiting times. Primary and community care is seeing more competitive tendering, with many contracts awarded to independent providers. Further evidence is still needed on the impacts of competition and potential mergers on quality, costs and regulation of different provider models.
Anita Charlesworth: The economics of integrationNuffield Trust
The document discusses regulatory issues related to integration in healthcare systems. It summarizes Monitor's new role as an economic regulator under the Health and Social Care Bill, including licensing providers, regulating prices, and promoting competition. It also discusses the empirical evidence around whether healthcare exhibits natural monopoly characteristics. While some studies find volume-outcome relationships and potential economies of scale, other research shows costs leveling off or increasing with scale beyond a relatively small threshold. The impact of mergers on costs and prices is mixed in the evidence.
Prof. Carol Propperin esitys VATT-päivässä 1.11.2016.
Professori Carol Propper on taloustieteen professori Imperial College London -yliopistossa Lontoossa, Iso-Britanniassa. Professori Propperin tutkimus keskittyy kannustin- ja kilpailukysymyksiin terveydenhuoltomarkkinoilla sekä yleisemmin kannustimien suunnitteluun ja vaikutuksiin julkisella sektorilla sekä julkisen ja yksityisen markkinoiden rajapinnalla. Hän on kuuluisa erityisesti tutkimuksistaan, joissa on tarkasteltu kilpailun ja valinnanvapautta lisäävien uudistusten vaikutuksia terveydenhuollon toimintaan Iso-Britanniassa.
This document discusses health technology assessment (HTA) and commissioning in the English NHS, with a focus on general practitioners (GPs). It provides background on HTA, which evaluates the clinical effectiveness and cost-effectiveness of health interventions. It also discusses key elements of the 2010 NHS reform plan and the history of GP commissioning in England since the 1990s, including GP fundholding schemes that gave GPs budgets to purchase some services. Evaluation found GPs were able to improve primary care and develop alternatives to hospital care, but faced challenges shifting resources from hospitals.
This document summarizes evidence on incentivizing competition in public services like healthcare. It finds that separating healthcare provision from funding through insurance schemes can introduce competition but consolidation limits its effects. Prices set prospectively for hospitals may increase quality and activity. Limited evidence shows negotiated prices between insurers and providers can decrease quality. More autonomy and control over surpluses for providers is associated with better outcomes but regulations often erode such autonomy. Competition among family doctors with limited cost sharing can increase satisfaction and quality to a small degree. However, strong consolidation trends and heavy regulation limit meaningful competition in many European healthcare systems.
1) The document summarizes recent reforms to the English National Health Service (NHS) proposed by the UK coalition government.
2) Key aspects of the reforms include transferring around 70% of the NHS budget to groups of general practitioners (GPs), increasing hospital autonomy and competition, and expanding patient choice.
3) The reforms aim to reduce central control over the NHS and introduce more market-based incentives, but also face significant implementation challenges and risks of disruption.
How diagnostics can drive efficiency within the NHSWalt Whitman
This document summarizes a presentation on how diagnostics can drive efficiency within the NHS. It notes that demand for diagnostic tests and waiting lists have increased in recent years without equivalent funding growth. Wide variation exists in diagnostic quality and access across regions. The presentation calls for diagnostics to be optimized by reducing unwarranted variation, improving data sharing and digital infrastructure, addressing capacity issues, and incentivizing efficiency. Recent NHS data collection and modeling identified over 30 million fewer tests, £33.6 million in cost savings, and opportunities to standardize practices and reduce costs in imaging services.
Tariff setting in Dutch Healthcare system, Johan van ManenOliver O'Connor
This document discusses health care reform and tariff setting in the Netherlands. It outlines two models used to calculate tariffs. Model I calculates average costs per diagnostic treatment combination (DBC) procedure based on a sample of hospitals, while Model II calculates total costs per DBC for each hospital. The document also describes how the proportion of regulated versus negotiable hospital costs and physician fees has changed over time as the system transitioned from centralized regulation to more market-based negotiations between insurers and providers.
Evaluating the impact of choice on place of careNuffield Trust
This document examines the effect of patient choice and Independent Sector Treatment Centres (ISTCs) on treatment location in England from 2003 to 2011. It finds that while ISTCs increased the number of procedures conducted outside the NHS, their overall effect was small due to a limited number of sites. The distribution of referrals also became more concentrated at the GP practice level during this period.
Tender scout imsta briefing series - collaboration between medical device s...Tony Corrigan
The document discusses medical device procurement in Ireland and the UK. It finds that collaboration between medical device suppliers and buyers can improve procurement outcomes. Currently in Ireland, price is often the dominant evaluation criteria for tenders rather than quality. Suppliers are recommended to improve the quality of their submissions and develop cost-benefit models to better demonstrate value. Industry groups should work with health services to increase capabilities in evaluating devices and support adoption of evaluation frameworks.
Carol Propper: The impact of competition and organisational integration on co...Nuffield Trust
The document discusses three main points:
1) Previous empirical evidence from the US and UK shows that competition in healthcare increases quality when prices are regulated.
2) Studies of the UK healthcare system found that hospitals exposed to more competition improved quality, reduced length of stay, and saw no expenditure increases. No evidence was found of increased inequalities.
3) Research on hospital consolidations in the UK found little cost reduction or quality improvements despite being costly to implement. Overall, competition seems to be beneficial to the UK system while consolidation has provided few clear gains.
Judith Smith: Priority setting in the reformed NHSNuffield Trust
The document discusses the challenges of priority setting in the reformed NHS. It notes the current financial context of flat funding and rising costs and demand. It outlines the key proposals in the Health and Social Care Bill, including greater clinical commissioning and competition. However, it argues that priority setting will be difficult for new clinical commissioning groups given their inexperience and need to make hard funding choices. It identifies several critical issues that will need to be addressed, including the roles of the NHS Commissioning Board, local authorities, competition policy, and ensuring priority setting considers the whole health budget.
This document summarizes a report by the Massachusetts Division of Health Care Finance and Policy examining price variation for healthcare services in Massachusetts. Some key findings include:
- Prices paid for the same hospital and physician services varied significantly, with at least a three-fold difference for every service examined.
- Higher-priced hospitals tended to have higher patient volumes for the services analyzed.
- There was little correlation between hospital quality scores and prices paid, though some lower-priced hospitals had slightly higher quality scores.
- Modeling payments to reflect a narrower range could yield estimated savings of $267 million for hospital and physician services.
1115 aine carroll clinical leaders forum nhc integrated care turning healthca...investnethealthcare
This document summarizes a presentation on integrated care given at the National Healthcare Conference in 2015. It discusses different types of integrated care including horizontal, vertical, and within sectors. Integrated care aims to provide coordinated services across providers and settings to support patients. Barriers to integrated care include fragmentation, distrust, and lack of coordination between strategy and operations. National clinical programs in Ireland have led to improved outcomes for conditions like heart attacks, surgery, and stroke through more integrated models of care. However, challenges remain around resources, hierarchies, and fully implementing integrated approaches across the healthcare system.
Splash 4 partners tele icu moving beyond the early inningsSplash 4 Partners
This document discusses the tele-ICU industry. It defines a tele-ICU as using remote monitoring to provide intensive care support. The document outlines the history and growth of the tele-ICU market from its beginnings in 1998 to becoming more widely adopted. It also compares tele-ICU to other telemedicine services and discusses limiting factors for telemedicine adoption like reimbursement rates and state licensing.
Splash 4 partners tele icu moving beyond the early innings Splash 4 Partners
This document discusses the tele-ICU industry. It defines a tele-ICU as using remote monitoring to provide intensive care support. The document outlines the history and growth of the tele-ICU market from its beginnings in 1998 to present day expanding adoption. It also compares tele-ICU to other acute telemedicine services and discusses limiting factors for telemedicine adoption like reimbursement rates and state licensing.
Hugh Gravelle: The impact of care quality on patient choiceNuffield Trust
Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
Andrew Taylor: Competition in the NHS: progress and prospectsNuffield Trust
This document summarizes Andrew Taylor's presentation on competition in the NHS. It discusses progress on patient choice in acute elective care and primary care, as well as competitive tendering. It also examines issues around NHS mergers, identifying possible benefits, and the impact of vertical integration on patient choice and competition. Finally, it discusses the potential for a third party access regime in the NHS to promote further competition.
Similar to LDI Research Seminar-Does Hospital Competition Improve Public Hospitals’ Productivity? Evidence from the English NHS Patient Choice Reforms (20)
This study analyzed insurance claims data from before and after the implementation of the Federal Mental Health Parity and Addiction Equity Act to examine the effects of parity on substance use disorder treatment. The results showed:
1) There was no change in the use of substance use disorder services or the total annual spending per enrollee on these services (which increased by only $10 per enrollee).
2) There was also no change in out-of-pocket spending for substance use disorder treatment users or several HEDIS quality measures related to identification and initiation of treatment.
3) This suggests that concerns about parity greatly increasing health care costs related to substance use disorder treatment were unfounded.
This study analyzed insurance claims data from before and after the implementation of the Federal Mental Health Parity and Addiction Equity Act to examine the effects of parity on substance use disorder treatment. The results showed:
1) There was no change in the use of substance use disorder services or the total annual spending per enrollee on these services (which increased by only $10 per enrollee).
2) There was also no change in out-of-pocket spending for substance use disorder treatment users or several HEDIS quality measures related to identification and initiation of treatment.
3) This suggests that concerns about parity greatly increasing health care costs related to substance use disorder treatment were unfounded.
This study compared retention rates, satisfaction, and safety between intimate partner violence (IPV) research participants paid via wireless gift cards versus cash. Participants receiving gift cards completed significantly more of the 12 weekly phone surveys (average 8.3 vs 6 calls). Over 90% of gift card recipients expressed satisfaction, and 60% preferred this method. While safety did not differ, wireless incentives may improve retention in repetitive IPV research that can involve remote data collection.
This study analyzed data from 658 insured pregnant women in a Midwestern county to compare risks and outcomes between those who did and did not utilize the emergency department (ED) during their peripartum period. The study found that 218 women (33%) visited the ED at least once during this time. ED users were more likely to experience psychosocial risks like postpartum depression and smoking, have poorer birth outcomes like prematurity, and have inadequate prenatal care. After adjusting for demographic factors, ED use was associated with a higher likelihood of postpartum depression, smoking during pregnancy, unstable housing, delayed prenatal care initiation, and missing a postpartum visit.
This study conducted a telephone survey of labor and delivery units at U.S. hospitals to determine the prevalence of hospital policies addressing non-medically indicated deliveries prior to 39 weeks gestation. They found that 66.5% of responding hospitals reported having such a policy. Hospitals in states with initiatives to reduce early deliveries were more likely to have a policy, with 67.8% of hospitals in initiative states reporting a policy compared to 62.1% in non-initiative states. The majority (68.8%) of policies were coded as having a "hard stop" against early deliveries. The study concludes that state initiatives can effectively encourage more hospitals to adopt restrictive policies on non-medically indicated early deliver
This study explored a broader range of adverse childhood experiences reported by low-income adults from Philadelphia compared to those measured in previous research. The researchers conducted focus groups with 119 participants who generated a list of childhood stressors across 10 domains. The most commonly reported experiences were issues within family relationships, community safety threats, personal victimization, and economic hardship. The study concludes that considering a wider range of adversities is important for understanding health impacts on low-income urban populations.
This document summarizes a mixed-methods study examining the relationship between mental health therapists' attitudes towards evidence-based practices (EBPs), perceptions of organizational factors, and degree status. The study found that doctoral-level therapists with positive attitudes reported more autonomy, while those with less positive attitudes reported requirements to use CBT and lack of time. Non-doctoral therapists reported lack of resources, space, funding, and regular client access as barriers. Managerial support was a facilitator for all therapists. The study provides insight into implementation challenges faced in community clinics from front-line perspectives.
This document proposes a model where doulas receive training in cognitive behavioral therapy (CBT) principles from staff at an integrated maternal wellness clinic. The objectives are to incorporate doulas into standard practice while providing training, and to utilize doulas to increase implementation of evidence-based CBT for common mental health issues in the perinatal period like anxiety and depression. Limitations include challenges of implementing a novel intervention and ensuring standardized training, protected staff time, and adherence to practice guidelines.
This study piloted a modified social skills intervention for children with ASD implemented by school personnel in public school settings. The intervention focused on facilitating peer engagement during lunch and recess. Results showed improvements in social network centrality and joint engagement for children who received the immediate treatment compared to those in the waitlist control. However, barriers like unclear staff roles, lack of support, and loss of recess time prevented long-term sustainability. Future work is needed to address school-level barriers to implementation and adapt interventions to fit individual school contexts.
This study examined the healthcare system supports for internists caring for young adult patients with chronic illnesses that began in pediatric care. Semi-structured interviews were conducted with 21 internists across 4 states. The interviews identified 5 major themes of healthcare system burdens experienced by internists, including difficulty identifying patients' medical teams, inadequate time for complex patients, significant administrative burden, lack of social/case management support, and financial constraints. The interviews also identified 3 potential strategies to improve supports, such as formalizing transfer processes, maximizing electronic records/communication, and leveraging patient-centered medical homes and bundled payments.
Most internists found more similarities than differences in caring for young adults with intellectual and developmental disabilities (I/DD) and elderly adults with dementia. Both populations require longer office visits and more staffing resources due to complex health histories. Obtaining records and coordinating care can be difficult for both. Reliance on advocates, community services for transportation and supervision, and vulnerability to insurance changes are also similarities. While specific diseases differ, models for geriatric care could potentially address supervision and caretaking needs for adults with I/DD. Strengthening safety net services would help low-income families and elderly patients with dementia or I/DD.
This study examines the association between patient perceptions of case manager performance and satisfaction with care, as well as the relationship between perceptions of case managers and primary care providers (PCPs) and subsequent healthcare utilization. The study analyzed survey and claims data from over 2,000 patients receiving primary care from a medical home model with embedded case managers. The results found that higher ratings of both case manager and PCP performance were independently associated with greater patient satisfaction. The study concludes by noting that perceptions of case management may impact health outcomes and behaviors, warranting further analysis of utilization patterns.
This document analyzes survey data from 2002-2010 on HIV testing rates and chronic disease screening in Southeastern Pennsylvania. It finds that HIV testing rates are lower than screening for other chronic diseases. Populations receiving care at community health clinics, emergency rooms, or with no primary care are more likely to get HIV testing than those at private clinics. While community health clinics perform similar to private clinics on chronic disease screening, those using emergency rooms or with no primary care are less likely to receive routine chronic disease screening. Primary care physicians adhere to guidelines for screening of conditions like blood pressure and cancer but may neglect appropriately screening for HIV.
This study analyzed survey data from 50,698 individuals in Southeastern Pennsylvania between 2002-2010 to compare HIV testing rates to other routine health screenings. It found that HIV testing rates were lower than for other conditions. Those receiving care at community health clinics, emergency rooms, or with no primary care had higher odds of receiving an HIV test compared to private clinics. While community health clinics performed similarly to private clinics on other screenings, emergency rooms and no primary care had lower rates. The study suggests primary care physicians may neglect appropriate HIV screening of patients despite adhering to other screening guidelines.
1. The document discusses high value cost conscious care and whether it constitutes rationing or rational care.
2. It notes that health care costs in the US continue to rise significantly each year, with diagnostic imaging being a major driver of increasing costs.
3. Data from 6 large health systems showed large variations in diagnostic imaging rates between different regions without clear clinical benefits, indicating opportunities for more rational use of imaging to improve quality and reduce costs.
This document summarizes key findings from RAND research on health care spending in the United States. It finds that between 1999-2009, health care costs grew substantially for a median-income American family, consuming money that could have otherwise been used to pay down debt, save for retirement, or pay for education. While Americans received more medical services, the quality of care was still suboptimal, with recommended care received only about 55% of the time. The document also examines different approaches to reducing health care costs, finding that high-deductible health plans with deductibles over $1,000 were effective in reducing spending.
The document outlines Marc Atkins' presentation goals which include reviewing concerns with the current U.S. children's mental health care system, justifying a focus on schooling using ecological principles and a public health framework, presenting an experimental intervention model and preliminary results, and discussing future directions. It then lists the collaborators involved in the research from various universities.
The document summarizes a study that analyzes the effects of the 2010 Affordable Care Act's dependent coverage mandate on young adults' health insurance coverage and labor market behavior using data from the 2008 panel of the Survey of Income and Program Participation. The study finds that the policy led to a 3.3 percentage point reduction in uninsurance among young adults ages 19-25, a 6.2 percentage point increase in dependent coverage through a parent's employer-sponsored insurance, and evidence of increased labor market flexibility for young adults.
This document provides a template for creating scientific posters. It includes suggestions for formatting, design principles, and sections like the title, abstract, methods, results, and conclusions. The template is meant to simplify poster creation and emphasize key points for viewers through techniques like italics, boldface, and effective use of space. Proper formatting of images, tables, and graphs is also discussed. The goal is to design posters that are easy to understand and focused on the needs of the audience.
1) Current state of quality and safety in healthcare is poor, with routine safety processes failing regularly and preventable adverse events occurring commonly.
2) High reliability organizations like commercial aviation have achieved much higher levels of safety through effective process improvement, a strong safety culture, and principles of collective mindfulness.
3) The Joint Commission aims to transform healthcare into a high reliability industry through initiatives like robust quality measurement, establishing accountability criteria for measures, and promoting high reliability principles.
More from Leonard Davis Institute of Health Economics (20)
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Part II - Body Grief: Losing parts of ourselves and our identity before, duri...
LDI Research Seminar-Does Hospital Competition Improve Public Hospitals’ Productivity? Evidence from the English NHS Patient Choice Reforms
1. Does Hospital Competition Improve Public Hospitals’ Productivity?
Evidence from the English NHS Patient Choice Reforms
Zack Cooper
The Centre for Economic Performance
The London School of Economics
2. MOTIVATION
Ambiguous evidence on the effect of competition on quality and productivity
– Fixed price competition prominent in Medicare, English NHS, and Dutch health
system;
– US (and UK) going further and are allowing new providers (including ambulatory
surgical centers) to enter the market and compete alongside traditional providers;
– Affordable Care Act potentially reduces competition by encouraging vertical
integration.
What impact does this have on quality and productivity?
– Empirical evidence on hospital competition is ambiguous, in part because of the
challenge of obtaining causal estimates on competition and the difficulty of measuring
productivity (Kessler and McClellan, 2000, Gowrisankaran and Town, 2003);
3. OVERVIEW
A series of quasi-natural experiments to test the impact of hospital competition on providers’
quality and productivity
• Identification: In 2006, a set of pro-competition reforms introduced across England
“The arrival of ‘patient choice’ - the right to choose, initially from at least four
hospitals, and by 2008 from any hospital prepared to meet NHS standards and
prices - is a symbolic moment in the government’s endeavor to use market forces
to drive up health service performance”, Nick Timmins, Financial Times,
December 31, 2005
• Research design: difference-in-difference style estimation looking at whether hospitals
located in more competitive markets pre-reform had bigger improvements in performance
after the reforms were introduced relative to hospitals in monopoly markets
– Public and private hospital locations in England are historically determined;
– Policy was universal across England;
– Patient level data with over 2+ million observations with four years pre-reform and five
years post-reform
4. RESEARCH QUESTIONS
An analysis of the impact of competition and private market entry on incumbent public hospitals
1. Did the introduction of hospital competition lower death rates in areas facing more
competition?
2. Did hospital competition between public providers lead to productivity gains?
3. Did the entrance of private providers (ambulatory surgical centers) improve public
providers’ productivity?
4. Did the entrance of new private providers leave incumbent providers treating a more
costly mix of patients?
5. SUMMARY
Public sector competition improved quality and productivity; private sector competition produced
did not produce productivity gains
• 1.s.d. increase in hospital competition pre-reform associated with 6.7% relative reduction
in AMI mortality post reform (saving approx 300 lives per year in ‘06, ‘07, and ‘08)
• Competition between public sector providers improved productivity - 1 hospital increase
associated with 4-9% increase in lean production;
• Private sector entrance did not help/harm lean operations but led to risk-selection;
• Incumbent public hospitals located in areas with more private providers were left with an
older and less wealthy mix of patients than led to £700,000 + excess costs from 2006 -
2010 per hospital;
• All observed changes in quality and productivity correspond precisely to the introduction of
the reforms. All results are robust across a range of specifications and across a number
of different measures of market structure
6. THE NHS REFORMS CREATED HOSPITAL COMPETITION
Involved changes to the demand and supply side in England + transactional reforms
Demand Side Supply Side
- Patient choice -Increased hospital
autonomy (retain
- Publicly provide info on surplus)
quality
- Allowed private
providers to deliver
care
Competition Between Providers
Regulation
Transactional Reform
- Creation of
Healthcare -Prospective, fixed
Commission & Monitor price payment system
- Paperless referral
system
7. TIMELINE OF THE NHS REFORMS
The reforms came in on a rolling basis from 2004 - 2008
2002 2003 2004 2005 2006 2007 2008 2009 2010
Patient Fixed
choice price Choice of Extended
pilots tariff for 4 local choice
FT trusts providers network
begin Any NHS-funded
(FTs,
some patient in England
private can attend any
public or private
Fixed provider in the
NHS Choose
price country
and Book
tariff for becomes
all operational
trusts
Steady increases in NHS Funding
9. TIMELINE OF THE NHS REFORMS
The reforms came in on a rolling basis from 2004 - 2008
2002 2003 2004 2005 2006 2007 2008 2009 2010
Patient Fixed
choice price Choice of Extended
pilots tariff for 4 local choice
FT trusts providers network
begin Any NHS-funded
(FTs,
some patient in England
private can attend any
public or private
Fixed provider in the
NHS Choose
price country
and Book
tariff for becomes
all operational
trusts
Steady increases in NHS Funding
10. TIMELINE OF THE NHS REFORMS
The reforms came in on a rolling basis from 2004 - 2008
2002 2003 2004 2005 2006 2007 2008 2009 2010
Patient Fixed
choice price Choice of Extended
pilots tariff for 4 local choice
FT trusts providers network
begin Any NHS-funded
(FTs,
some patient in England
private can attend any
public or private
Fixed provider in the
NHS Choose
price country
and Book
tariff for becomes
all operational
trusts
Steady increases in NHS Funding
11. ISSUES ESTIMATING THE EFFECT OF HOSPITAL COMPETITION
This literature is marked by a number of estimation issues
• Question of how to measure market structure;
• Hospital market structure is typically endogenous to providers’ performance (usual
reduced form issue);
• Is this a ‘city’ thing?
• Crucial to demonstrate that the reforms were not driven by pre-reform trends in AMI death
rates.
12. DATA
Patient-level data on all NHS patients from 2002 - 2010
• Health episodes and statistics (HES) data include all patient observations from 2002 through
2010 ~ 2 million observations
– Focus on elective, non-revision knee replacement, hip replacement, hernia repair and
arthroscopy (high volume elective surgeries)
• Patient characteristics (age, sex, Charlson co-morbidity index, home address)
• Able to link patient characteristics to local area characteristics (income vector of the Index of
Multiple Deprivations)
• Provider characteristics (hospital teaching status, size, ownership)
• Use patient’s registered GP practice (8000+) to calculated straight-line distances from GP to
hospitals;
• Data on private sector providers from Laing and Buisson, a private data holding company;
• Use data on population density from the Office of National Statistics 2001 census at the
Middle Super Output Area
13. MEASURING MARKET STRUCTURE
Twin challenges of avoiding endogenous measures and avoiding capturing urban density
Fixed radius market - i.e 20km radius draw around each GP
+ Radius size unrelated to provider performance
- urban rural bias: likely overestimates market size in urban areas; under estimates market size in
rural areas
Variable radius market - i.e. radius that captures 95% of GP referrals
+ Radius size more accurately captures true size of the market
- market size is potentially endogenous to performance
Travel-time based market - i.e. radius that captures 30-minute drive
+ Radius should more accurately capture the size of the market
+ Radius is exogenous to quality;
- In practice, 80+% correlation with fixed radius market
Administrative boundaries - i.e. market defined as an MSOA or county
+ Radius size unrelated to provider performance
- Market definitions are inaccurate if patients can travel across boundaries
Kessler and McClellan (2002) index - using predicted demand to measure concentration
+ Exogenous to providers’ performance
- highly correlated with fixed radius market because distance is main component of underlying
estimation of demand
14. STRATEGY FOR QUANTIFYING MARKET STRUCTURE
Our strategy was to show that results were robust across key measures of market structure
Also measure HHIs and counts
in:
• Fixed radius markets
• Travel time markets
• Smaller variable radius markets
Use predicted patient flows
Use IV for market structure
Carry out placebo test (school
competition
15. MARKET STRUCTURE IN ENGLAND
Fixed radius markets, travel-time based radius markets and predicted demand markets all
heavily correlated with population density
HHI within 20km Fixed Radius HHI within Travel-Time Radius Predicted Demand HHI
16. VARIABLE RADIUS MARKET IN ENGLAND
Our variable radius market is far less correlated with urban density
17. OUR MEASURE OF HOSPITAL QUALITY
We measured hospital quality using 30-day mortality from acute myocardial infarction
Rational for using AMI mortality:
1. AMIs are relatively frequent, easily observable with significant mortality rate (~14%)
2. There is a clear link between timely and effective treatment and survival
3. Not likely to be gaming
4. Emergency procedure where there’s not much opportunity for risk-selection (also
attenuates some endogeneity
5. Frequently used by governments (including in the UK) as a measure of hospital quality
6. Frequently used in this literature I.e. Kessler and McClellan (2000), Kessler and Geppert
(2005), Volpp et al. (2003), Gaynor et al. (2010)…
We observed links with other measures of performance in cross sectional firm level
data in 2009:
• Positively correlated with overall mortality (r = 0.33)
• Positively correlated with LOS (r = 0.30) and waiting times (r = 0.20)
• Positively correlated with patient satisfaction (r = 0.20)
18. OUR ESTIMATOR
We use a flexible estimator and show our results are robust across several specifications
– Deathijkt is an indicator for whether patient i, registered at GP j, treated at hospital k, at
time t died within 30-days of admission for an AMI (heart attack)
– t is a running counter of quarters since 2002
– is the policy break-point in the spline, which we regard as occurring in the start of the
new financial year in 2006
– zjt is our measure of market structure measured for each GP market j at time t
Flexible Estimator:
• Gives rise to a standard DiD estimator
• Gives rise to our preferred spline-based DiD trends estimator
19. OUR MODIFIED DIFF-IN-DIFF ESTIMATOR
This allows us to test for the existence of pre-reform trends
Outcome
Control
Treatment
Time
Policy-On Date
20. OUR MODIFIED DIFF-IN-DIFF ESTIMATOR
This allows us to test for the existence of pre-reform trends
Outcome
Control
Treatment
Time
Policy-On Date
(2006)
21. OUR MODIFIED DIFF-IN-DIFF ESTIMATOR
This allows us to test for the existence of pre-reform trends
Outcome
Control
Treatment
Time
Policy-On Date
(2006)
22. OUR MODIFIED DIFF-IN-DIFF ESTIMATOR
This allows us to test for the existence of pre-reform trends
Outcome
Control
Treatment
Treatment effect
Time
Policy-On Date
(2006)
23. OUR MODIFIED DIFF-IN-DIFF ESTIMATOR
This allows us to test for the existence of pre-reform trends
Outcome
Control
Treatment
Treatment effect
Time
Policy-On Date
(2006)
24. MAIN RESULTS
robust across various specifications with and without fixed effects and controls for patient
characteristics
nlhhi measured in variable radius market
25. MAIN RESULTS
robust across various specifications with and without fixed effects and controls for patient
characteristics
nlhhi measured in variable radius market
26. MAIN RESULTS
robust across various specifications with and without fixed effects and controls for patient
characteristics
nlhhi measured in variable radius market
27. MAIN RESULTS
robust across various specifications with and without fixed effects and controls for patient
characteristics
nlhhi measured in variable radius market
28. MAIN RESULTS
robust across various specifications with and without fixed effects and controls for patient
characteristics
nlhhi measured in variable radius market
29. Hospitals located in competitive markets began to lower their mortality
more quickly from 2006 onwards
Policy on
Source: Cooper et al. (2010)
30. Other Measures of Market Structure
The results are robust using HHIs within other market definitions
34. OVERVIEW
We separately identify the effect of public and private-sector competition on productivity
We take advantage of the phased introduction of the reforms
• Identification: a difference-in-difference style estimation strategy with market structure
interacted with year dummies
– Public and private hospital locations in England are historically determined;
– Policy was universal across England;
– Patient level data with over 2 million observations with four years pre-reform and five
years post-reform
– Public sector competition took force in 2006; private sector competition in 2007/8
– Use a measure of lean production that is unbiased by patient characteristics
• Questions:
– Q1: Did hospital competition between public providers improve hospital productivity?
– Q2: Did the entrance of private providers (ambulatory surgical centers) prompt
incumbent providers to improve their productivity?
– Q3: Did competition induce risk-selection and was this more pronounced with the
entrance of private providers
We measure productivity in incumbent providers
35. TIMELINE OF THE NHS REFORMS
The reforms came in on a rolling basis from 2004 - 2008
2002 2003 2004 2005 2006 2007 2008 2009 2010
Patient Fixed
choice price Choice of Extended
tariff for 4 local choice
pilots
FT trusts providers network
begin (FTs, Any NHS-funded
some patient in England
private can attend any
public or private
Fixed provider in the
NHS Choose
price country
and Book
tariff for becomes
all operational
trusts
Steady increases in NHS Funding
36. PUBLIC AND PRIVATE PROVIDERS DELIVERING NHS FUNDED CARE
We view the location of both public and private providers as exogenous to performance
• Public hospital locations date back to the founding of the NHS
– Large tertiary hospitals
– Mean of 825 total beds
• All private providers could see NHS funded patients if they were approved by the hospital
regulatory body and were willing to deliver care according NHS tariffs
– Mean of 49 beds;
– Mainly deliver elective surgery;
• We measure those who could have potentially delivered care, rather than those who did
• Private hospitals largely pre-date the founding of the NHS
– 158 of 162 prior to 2005
– 90% prior to 2000
– 72% prior to 1990
– Mean opening date: 1979
37. ESTIMATION STRATEGY
We use a difference-in-difference style estimator to identify public and private sector
competition
Count of public providers
Year dummies Hospital, GP and
(pre-reform) interacted with
procedure fixed effects
year dummies
losijkt = pub_countk • yt`β1 + priv_countk • yt`β2 + yt`δ + xijt`γ + θj + θk + θp + νijkt
Count of private providers Patient and hospital
(pre-reform) interacted with characteristics
year dummies
• Public and private counts are interacted with 1 and year dummies I.e. yt = [1 2003, 2004, 2005,
2006…2010]
• Error terms are clustered around GPs k
• β1 and β2 provide the year specific effects of public and private sector competition (off 2002)
• y_pret` = [2003 … 2005] and y_postt` = [y2006 y2007 …2010] for public sector competition and [y2007
y2008 … y2010] for private sector competition
• Assumptions
– Hospitals would have followed trend of monopoly providers if untreated;
– Hospitals located in more potentially competitive markets prior to the reforms would face
sharper incentives after the reforms were introduced
38. OUR MEASURE OF MARKET STRUCTURE
We create GP-centered markets that expand and contract in rural and urban areas
For each GP-practice, define radius r as the distance necessary to capture a circular
area around GP k that captures 330,000 adults over 18
– 333,000 people is roughly the population of adults in England divided by number of
public hospitals
– Also use market definitions that capture 666,000 adults and 999,000 adults
Separately measure the count of public hospitals and private hospitals inside these
market definitions
+ Public hospital locations are historical artifact that date back to the 1948 founding of
the NHS. We measure counts in 2002;
+ 158 of 162 private providers in England were established prior to the reforms
+ We measure the number of potential private providers
Center our markets on GP practice
+ Mimics market structure in England where patient chooses hospital with help from GP
+ market structure not endogenous to patient choice
39. PREFERRED MEASURE IS LESS CORRELATED WITH POP DENSITY
Fixed radius counts and counts in our population market superimposed on a map of England
Counts within fixed radius Counts within 666,000 person
market radius market
40. MEASURING HOSPITAL PRODUCTIVITY
We break patients’ length of stay into its two key components
Patient Admitted Patient’s Surgery Patient Discharged
Pre-surgery LOS Post-surgery LOS
• Overall length of stay has been used as a proxy for efficiency but seemingly quite affected
by patient characteristics (Gaynor et al. 2010, Martin and Smith 1996, Cutler et al. 1995
etc.)
• Post-surgery LOS is likely heavily influenced by patient characteristics
• Pre-surgery LOS should not be biased by patient characteristics for an elective surgery
– Turn around time between surgeries;
– Hospital admissions procedures;
– Staff management (right person right time)
• Lower pre-surgery LOS is capturing leaner operations
41. MECHANISM
We hypothesize that higher competition will be associated with reductions in LOS
Two mechanisms for competition driving reductions in LOS:
If reimbursement rate > MC, PPS (or PbR) encourages providers to increase activity
in order to increase revenues
Hospitals in more competitive markets have more opportunity to increase activity
through business-stealing
They reduce LOS to create room for new patients
Reductions in LOS driven by broad improvements in hospital management
performance
42. RESULTS FOR OVERAL LOS, PRE-SURGERY LOS, RISK-SELECTION,
COUNTERFACTUAL
Count of public providers
Year dummies Hospital, GP and
(pre-reform) interacted with
procedure fixed effects
year dummies
losijkt = pub_countk • yt`β1 + priv_countk • yt`β2 + yt`δ + xijt`γ + θj + θk + θp + νijkt
Count of private providers Patient and hospital
(pre-reform) interacted with characteristics
year dummies
62. PRE- AND POST-SURGERY LOS
Our preferred specification with GP and hospital fixed effects in our 666,000 market
Pre-surgery Post-surgery Most conservative estimates
Coef S.E. Coef S.E.
Count public - - - -
2003 * public 0.0038 0.0013 -0.0019 0.0053
2004 * public 0.0082 0.0017 0.0180 0.0060
2005 * public 0.0128 0.0021 0.0184 0.0069
Public Counts
2006 * public 0.0071 0.0023 -0.0066 0.0073
2007 * public -0.0012 0.0025 -0.0336 0.0077 • Pre-surgery relative reduction of 4.2%
2008 * public -0.0020 0.0024 -0.0421 0.0080
2009 * public -0.0096 0.0024 -0.0498 0.0082 • Post-surgery relative reduction of 2.6%
2010 * public -0.0156 0.0024 -0.0725 0.0089
Count Private - - - -
2003 * private 0.0028 0.0010 -0.0008 0.0046
2004 * private -0.0022 0.0013 -0.0198 0.0047
2005 * private -0.0056 0.0015 -0.0214 0.0053
2006 * private -0.0058 0.0018 -0.0176 0.0055 Private Counts
2007 * private -0.0028 0.0018 0.0025 0.0055 • No significant effect on pre-surgery
2008 * private -0.0012 0.0016 0.0094 0.0056
2009 * private 0.0021 0.0016 0.0165 0.0056 • Significant effect on post-surgery
2010 * private 0.0008 0.0016 0.0185 0.0062
Patient Car Yes Yes
GP F.E. Yes Yes
Trust F.E. Yes Yes
Year Dummies Yes Yes
Obs 2,039,070 2,039,070
R2 0.3477 0.7462
63. THE IMPACT OF PUBLIC COMPETITION ON PRE-SURGERY LOS
Graphical presentation of our preferred specification with GP and hospital fixed effects in our
666,000 market
64. THE IMPACT OF PRIVATE COMPETITION ON POST-SURGERY LOS
Graphical presentation of our preferred specification with GP and hospital fixed effects in our
666,000 market
70. TEST OF THE COUNTERFACTUAL
Results suggest that hospital position, not population density are driving main findings
Length of stay Age Socio-economic status Charlson index
Coef. S.E. Coef. S.E. Coet. S.E. Coef. S.E.
Population density - - - - - - - -
2003 * pop. density 0.0001 0.0003 -0.0006 0.0017 0.0000 0.0000 0.0002 0.0001
2004 * pop. density 0.0004 0.0003 -0.0008 0.0017 0.0000 0.0000 0.0004 0.0001
2005 * pop. density -0.0002 0.0003 -0.0016 0.0018 0.0000 0.0000 0.0005 0.0001
2006 * pop. density -0.0001 0.0003 0.0002 0.0018 0.0000 0.0000 0.0003 0.0001
2007 * pop. density -0.0004 0.0003 -0.0031 0.0017 0.0001 0.0000 0.0004 0.0001
2008 * pop. density 0.0003 0.0003 -0.0033 0.0017 0.0001 0.0000 0.0000 0.0001
2009 * pop. density 0.0005 0.0003 -0.0040 0.0018 0.0001 0.0000 0.0001 0.0002
2010 * pop. density 0.0010 0.0003 -0.0030 0.0018 0.0001 0.0000 0.0000 0.0002
2003 -0.1732 0.0102 0.2786 0.0687 0.0000 0.0004 0.0040 0.0049
2004 -0.3693 0.0105 0.6565 0.0690 -0.0008 0.0004 0.0278 0.0052
2005 -0.5532 0.0112 0.8222 0.0687 -0.0010 0.0004 0.0660 0.0056
2006 -0.7821 0.0118 0.9772 0.0705 -0.0012 0.0004 0.0928 0.0058
2007 -1.0685 0.0122 1.3807 0.0690 0.0094 0.0004 0.1098 0.0060
2008 -1.2386 0.0126 1.6415 0.0696 0.0131 0.0004 0.1536 0.0064
2009 -1.3590 0.0127 1.4349 0.0712 0.0126 0.0005 0.1858 0.0069
2010 -1.5183 0.0128 1.4146 0.0727 0.0132 0.0005 0.2542 0.0073
Patient Char Yes No No No
GP F.E. Yes Yes Yes Yes
Trust F.E. Yes Yes Yes Yes
Year Dummies Yes Yes Yes Yes
Obs 2,039,070 2,039,070 2,039,070 2,039,070
R2 0.7576 0.3429 .4243 0.1075
71. QUANTIFYING THE PRODUCTIVITY GAINS
We can calculate estimates of the cost/savings from reductions in LOS and rise of risk-selection
• An excess bed day in England cost approximately £225.00
• Reducing LOS for our four procedures would result in:
– 59,000 saved bed days; £13 million pounds in savings during that period
• Across the NHS, this would result in:
– 1.6 million fewer bed days; £356 million pounds savings
• Across the NHS, savings from reducing pre-surgery LOS would be approximately £40.3
million pounds
• From 2007 - 2010, the entrance of private providers left public hospitals treating older,
poorer patients patients, which was associated with a cost, measured from post-surgery
LOS alone, of £714,000 pounds per year
72. CONCLUDING THOUGHTS
The introduction of hospital competition in England was associated with moderate productivity
gains
• Competition between public tertiary hospitals led to moderate gains of productive
efficiency on the order of 4-9%.
• Competition between public and private did not lead to increases in productivity;
• The entrance of new private providers was associated with a small but significant increase
in the age and deprivation of patients at incumbent hospitals
– Cannot tell whether this was from these hospitals selecting against these patients or
whether wealthier younger patients themselves preferred to go private
• Clearly suggests that if we want to produce productivity gains, payments to hospitals
needs to more accurately take into account factors which may potentially lead to higher
costs
73. FURTHER WORK TO BE DONE ON THIS PAPER
• Placebo test using LOS for AMI and emergency fractured neck of femur;
• Test results using GLM estimator with negbin and gamma distributions
• Test that results are robust when excluding London
• Relax our assumption about the linear effect of competition
75. AN ANALYSIS OF HOSPITAL PRICING
A series of papers using new data with US Hospital transaction prices
• Claims data with transaction prices
• Series of articles:
– Documenting the variation in prices;
– Examining the impact of rising prices on overall health care spending;
– Examining the impact of hospital market structure on prices;
– Examining whether hospital cost-shifting occurs: does a reduction in Medicare and
Medicaid premiums lead to increases in the prices charged for private patients
• Jointly with John Van Reenen (LSE) and Marty Gaynor (CMU)
76. INTERNATIONAL COMPARISON OF HOSPITAL PERFORMANCE
• Patient-level data for the US, UK, Canada and the Netherlands
• Working to create matching cohort
• Examining whether there is more within or between country differences in hospital
performance as a tool to determine the impact of larger health systems issues
• Joint with Amitabh Chandra (Harvard), Therese Stukel (University of Toronto), Eddy Van
Doorslaer (Erasumus University)
77. SUBSTANTIAL HOSPITAL PRICE VARIATION
Component prices charged to a large private insurer for gallbladder removal at hospitals within
a medium sized US market