The impact of Community Health Centers on inappropriate use of emergency services.

Community Health Centers offer coordinated and comprehensive responses to primary care needs. Our study aims at assessing whether the introduction of such organizational model improved health outcomes measured by inappropriate emergency visits among diabetics in the Emilia-Romagna region of Italy. Using difference-in-differences methods within a staggered treatment setting, we estimate the effect of Community Health Center participation on inappropriate hospital emergency visits between year 2010 and year 2016. We distinguish between emergency department admissions for varying time spans, occurring at daytime during working days, at night-time, as well as during weekends. We show that, the causal effect of the adoption of the community care model leads to a reduction in the probability of inappropriate admissions by an amount ranging between 1.6 and 1.7% points during working days at daytime, with large facilities responsible for most gains by experiencing a decrease ranging between 4 and 3% points. Conversely, we detect no difference at night-time and during weekends. Our results point out that the coordinated care model increases appropriateness among vulnerable patients, and that extending opening hours and the range of services can further enhance such benefits.

How do hospital-specialty characteristics influence health system responsiveness? An empirical evaluation of in-patient care in the Italian region of Emilia-Romagna.

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply-side factors. This paper addresses that research gap by analysing the role of hospital-specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in-patients treated in public hospitals within the Italian Region of Emilia-Romagna. The analysis is carried out by adopting a 2-step procedure. First, we use patients' self-reported data to derive 5 measures of responsiveness at the hospital-specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross-sectional regressions to investigate the association between patients' responsiveness and potential supply-side drivers, including waiting times, staff workload, the level of spending on non-clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply-side drivers considered.

Autonomy and performance in the public sector: the experience of English NHS hospitals.

Since 2004, English NHS hospitals have been given the opportunity to acquire a more autonomous status known as a Foundation Trust (FT), whereby regulations and restrictions over financial, management, and organizational matters were reduced in order to create incentives to deliver higher-quality services in the most efficient way. Using difference-in-difference models, we test whether achieving greater autonomy (FT status) improved hospital performance, as proxied by measures of financial management, quality of care, and staff satisfaction. Results provide little evidence that the FT policy per se has made any difference to the performance of hospitals in most of these domains. Our findings have implications for health policy and inform the trend towards granting greater autonomy to public-sector organizations.

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different diagnosis-related groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia-Romagna, we test whether a 1-year increase in DRG prices induced public hospitals to increase their volume of activity and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the 2 years after the policy change than in later years, and for providers with a lower excess capacity in the pre-policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices had no impact on the proportion of patients waiting more than 6 months. Finally, we find no evidence of a significant effect on patients' average length of stay. Copyright © 2016 John Wiley & Sons, Ltd.

Examining variations in hospital productivity in the English NHS.

OBJECTIVES: Numerous papers have measured hospital efficiency, mainly using a technique known as data envelopment analysis (DEA). A shortcoming of this technique is that the number of outputs for each hospital generally outstrips the number of hospitals. In this paper, we propose an alternative approach, involving the use of explicit weights to combine diverse outputs into a single index, thereby avoiding the need for DEA. METHODS: Hospital productivity is measured as the ratio of outputs to inputs. Outputs capture quantity and quality of care for hospital patients; inputs include staff, equipment, and capital resources applied to patient care. Ordinary least squares regression is used to analyse why output and productivity varies between hospitals. We assess whether results are sensitive to consideration of quality. RESULTS: Hospital productivity varies substantially across hospitals but is highly correlated year on year. Allowing for quality has little impact on relative productivity. We find that productivity is lower in hospitals with greater financial autonomy, and where a large proportion of income derives from education, research and development, and training activities. Hospitals treating greater proportions of children or elderly patients also tend to be less productive. CONCLUSIONS: We have set out a means of assessing hospital productivity that captures their multiple outputs and inputs. We find substantial variation in productivity among English hospitals, suggesting scope for productivity improvement.

Investigating the governance of autonomous public hospitals in England: multi-site case study of NHS foundation trusts.

OBJECTIVE: To investigate the external and internal governance of NHS foundation trusts (FTs), which have increased autonomy, and local members and governors unlike other NHS trusts. METHODS: In depth, three-year case studies of four FTs; and analysis of national quantitative data on all FT hospitals and NHS Trust hospitals to give national context. Data included 111 interviews with managers, clinicians, governors and members, and local purchasers; observation of meetings; and analysis of FTs' documents. RESULTS: The four case study FTs were similar to other FTs. They had used their increased autonomy to develop more business-like practices. The FT regulator, Monitor, intervened only when there were reported problems in FT performance. National targets applying to the NHS also had a large effect on FT behaviour. FTs saw themselves as part of the local health economy and tried to maintain good relationships with local organisations. Relationships between governors and the FTs' executives were still developing, and not all governors felt able to hold their FT to account. The skills and experience of staff members and governors were under-used in the new governance structures. CONCLUSIONS: It is easier to increase autonomy for public hospitals than to increase local accountability. Hospital managers are likely to be interested in making decisions with less central government control, whilst mechanisms for local accountability are notoriously difficult to design and operate. Further consideration of internal governance of FTs is needed. In a deteriorating financial climate, FTs should be better placed to make savings, due to their more business-like practices.

Navigating uncharted waters? How international experience can inform the funding of mental health care in England.

BACKGROUND: Activity-based funding mechanisms are widely used in acute care. In England, payment by results is being extended to mental health care, but its financial viability is unclear. AIMS: To identify international examples of activity-based funding systems for mental health care and to inform the development of a national tariff in England. METHOD: The international literature on payment systems for mental healthcare services was reviewed. Payment systems were appraised from an economic perspective. Variations in cost between English mental healthcare providers were explored using routine inpatient data on length of stay in 2007/8. RESULTS: The review identified activity-based mental healthcare payment systems in five countries. International experience highlights the need for gradual and stepwise implementation; the use of budget neutrality adjustments; top-slicing of budgets to stabilise provider income; and use of the classification system to drive improvements in quality and cost-effectiveness. All systems adjusted for length of stay, but methods varied. Comparing English mental healthcare providers, median length of stay ranged from 2 to 42 days for emergency admissions and from 0 to 56 days for elective admissions. CONCLUSIONS: New payment systems must account for the economic incentives they embody, and appropriate adjustments for variations in length of stay are essential.

Private sector treatment centres are treating less complex patients than the NHS.

OBJECTIVES: In England, patients can choose to have their NHS elective care delivered by private (or 'independent sector') providers or by the NHS. Providers are paid a fixed tariff for each type of procedure. Our objectives were to compare NHS providers with private treatment centres in terms of (a) the quality of data coding and (b) patient complexity. DESIGN: We compared elective patients aged 18 years and over treated in the NHS and private sectors using the Hospital Episode Statistics (HES) data for 2007-2008. The absence of diagnostic information was used as a measure of data quality. We analysed differences in complexity for each of the 30 Healthcare Resource Groups (HRGs) that together account for 78% of coded private treatment centre activity. Statistical significance was assessed at the 1% level. SETTING: Hospitals and treatment centres. MAIN OUTCOME MEASURES: Patient complexity was assessed by four characteristics: age; number of diagnoses; number of procedures; and income deprivation of residential area. RESULTS: NHS providers treated almost 7 million adult elective patients in 2007-2008. Fewer than 100,000 patients were treated by private providers (1.3% of elective activity). Less than 1% of NHS patients lacked diagnostic information compared to 36% of patients treated by private providers. For the top 30 HRGs, NHS patients had significantly (p<0.01) higher levels of co-morbidity, underwent more procedures and were more likely to come from deprived areas compared with patients treated by private providers. Although patients treated in private settings tended to be younger, the difference was not statistically significant. CONCLUSIONS: Some private companies provide poor quality data. In general, the NHS is treating more complex patients than private providers. If complexity drives costs, then a fair reimbursement system would require higher payments for NHS providers.

Waiting times and socioeconomic status among elderly Europeans: evidence from SHARE.

Waiting times for specialist consultation and non-emergency surgery are often considered an equitable rationing mechanism in the public healthcare sector, because access to care is not based on socioeconomic status. This study tests empirically this claim using data from the Survey of Health, Ageing and Retirement in Europe (SHARE). The sample includes nine European countries: Austria, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain and Sweden. For specialist consultation, we find that individuals with high education experience a reduction in waiting times of 68% in Spain, 67% in Italy and 34% in France (compared with individuals with low education). Individuals with intermediate education report a waiting-time reduction of 74% in Greece (compared with individuals with low education). There is also evidence of a negative and significant association between education and waiting times for non-emergency surgery in Denmark, the Netherlands and Sweden. High education reduces waits by 66, 32 and 48%, respectively. We also find income effects, although generally modest. An increase in income of 10 000 Euro reduces waiting times for specialist consultation by 8% in Germany and waiting times for non-emergency surgery by 26% in Greece. Surprisingly, an increase in income of 10 000 Euro increases waits by 11% in Sweden.