Health Care Provision and Expenditures

Einleitung / Introduction

Political budget cycles describe the increase of public spending before elections and its cut afterward. It is assumed that incumbent ministers thereby signal their competence to the electorate. Instead of increasing total public health care expenditure (PHCE), rising particular sub-categories can be seen as much more efficient to “buy votes”. My analysis takes up this argument by evaluating total PHCE as well as its sub-categories. Also, I evaluate the actual number of certain outcomes of fiscal policies like the number of hospitals. I argue that such indicators are more visible and can be directly linked to the actions of a minister by the electorate. The decentralized Swiss political system gives the cantons substantial freedom in implementing the national health care act in line with their preferences. The thereby emerging variety of health care systems leads to a wide range of different cost outcomes. The prevalent lack of fiscal transparency and the majoritarian election system can be seen as additional motivators for political budget cycles.

Methode / Method

For my analysis, I use panel data to 23 Swiss cantons for the years 1991 to 2016 and introduce year and canton fixed effects. Surprisingly, existing literature barely considers the signaling towards the electorate and the lag in the data record. I focus on the year in which I expect opportunistic policies to take place.

Ergebnisse / Results

I find the average total PHCE growth to be 20€ per capita per year, which increases to 40€ in election years. Effects are only significant in periods with re-elections, compared to periods in which no incumbent runs for office. It turns out that the sub-category “hospitals” is the main driver of political budget cycles. For indicators of PHCE, I find significant effects for acute care hospitals and beds. At the same time, a significant decrease is found for the number of psychiatry beds before and during election years. These findings point to redistribution within public health care items. A similar pattern can be observed for private and public acute care hospitals.

Zusammenfassung / Conclusion

The increase in total PHCE doubles in elections years when a health minister runs for re-election. The significant difference between the effect of all elections and the one with only re-elections alludes to the opportunistic motive of incumbent health ministers. Hospital spending is the main driver for this result. Outcome-based indicators confirm these findings. There is evidence for a redistribution pattern among total PHCE. The observed political budget cycle effects can be seen as a result of the salience of health ministers and the hospital policy they are responsible for. Strategies to implement these opportunistic policies could be pursued with e.g. deliberately timed policy changes or privatization decisions.

AutorInnen

Christoph Thommen, Universität Basel

Einleitung / Introduction

As the number of patients with chronic diseases increases in an aging population, the need for better coordination of care in the ambulatory sector in Germany has been recognized. The lack of continuous coordination among family and specialist physicians in primary care can lead to suboptimal treatments and health outcomes, as well as higher healthcare expenditures per patient. At the same time, there exists evidence that collaborative and integrated care models are associated with improved health outcomes for certain patient groups. To this end, physician networks in form of regional associations of office-based physicians of various specializations were implemented in the German primary care sector. This paper aims to evaluate performance of this new form of collaborative care. More specifically, it investigates if patients treated within organized physician networks (QuATRo) show better health outcomes compared to patients treated in regular care. It also examines if such facets of health care provision as coordination of treatment, preventative services and pharmacotherapy are excelling in organized physician networks.

Methode / Method

To test the primary hypothesis that care in QuATRo networks leads to improved health outcomes, the patient-population of people aged over 65 who have at least one of the thirteen most common ambulatory care-sensitive conditions (ACSC) is considered. Hospitalization rates of QuATRo patients are compared to a control group (patients treated in regular care) within each of the thirteen ACSCs. The control group is constructed using nearest neighbor propensity score matching. Further network performance indicators covering prevention of diseases, pharmacotherapy and coordination of care are computed and analyzed. Significance is tested using a two-sample t-test. Extensive sensitivity analysis of the results is carried out.

Ergebnisse / Results

Even though no significant large (almost always <1%) and consistent differences in hospitalization rates could be identified between the two groups, the majority of process indicators (especially preventative services and coordination of treatment) are significantly better in the QuATRo networks. There is no evidence for more secure pharmacotherapy in QuATRo networks. The results are robust across various sensitivity approaches.

Zusammenfassung / Conclusion

These results suggest that care provision in QuATRo networks is beneficial for patients in general, but might not be reflected in reduced hospitalization rates. The study contributes to ongoing research about the effectiveness of organized physician networks in Germany and collaborative care in general. Further research is necessary to understand the benefits of more coordinated primary care, especially for the group of patients with chronic diseases.

AutorInnen

Iryna Iashchenko, Technical University Munich, Ludwig-Maximilians-University Munich

Leonie Sundmacher, Technical University Munich

Einleitung / Introduction

Integration has emerged as a priority in transforming health care delivery to improve care. Developing integrated care (IC) solutions across the medical and social service sectors has gained momentum with emerging evidence favouring the integration of public health and community service agencies. Key for effective community health care management systems is the integration of stakeholders during the development of new care solutions. However, engaging stakeholders in developing new forms of care is linked with overcoming sectoral boundaries between the public, private and non-profit sectors; each of which is characterized by different visions, missions, and incentives. Given this setting, our study aims to explore the conditions for developing sustainable and effective IC solutions across sectors.

Methode / Method

We conducted an in-depth case study of a cross-sector partnership aiming to develop a population-based IC model in northern Germany. Physicians, health insurers, a health management company, a public health authority and other stakeholders in social and health care jointly developed and implemented the IC model. Our primary data source were 21 interviews from 2017 and 12 interviews from a validation round in 2019. We also drew on 82 case-related documents and 8 meeting participations. We performed thematic text analysis after abductively coding our data in multiple coding cycles. Three coders were involved in the coding procedure. Disagreements were discussed and resolved leading to a shared interpretation of our data.

Ergebnisse / Results

We identified four overarching conditions for successful stakeholder engagement in developing models of integrated care: (1) well-defined organization and communication structures; (2) a culture of variety and interconnectedness; (3) engaged and collaborative stakeholders; and (4) effective resource management. We provide a framework for these conditions alongside detailed insights into each.

Zusammenfassung / Conclusion

Our findings advance existing knowledge on stakeholder engagement and inform strategy professionals and policy makers about the requirements for successful IC development across sectors. Particularly, practitioners should (1) ensure a certain degree of formalization, i.e. pre-defined structures and procedures; (2) acknowledge and organize variety, e.g. by introducing a conflict management body; (3) effectively pool and manage resources; and (4) build on and promote team- and change-oriented stakeholder characteristics. Our framework might serve as a checklist for practitioners or as a conceptual framework for future research.

AutorInnen

Henrike Schmidt, Hamburg Center for Health Economics

Eva-Maria Wild, Hamburg Center for Health Economics

Carl Rudolf Blankart, Kompetenzzentrum für Public Management - Universität Bern

Einleitung / Introduction

We document the impact that centralized public procurement of medical devices has on procurement outcomes. Using data on purchase orders of medical devices made by public health units in one Italian region between 2015 and 2018 matched with delivery dates, we exploit the fact that since January 2016, contracts for syringes, needles and medications have to be awarded by national or regional procurement agencies. We find that unitary prices paid for medical devices subject to this policy decrease by about 30% and delivery times increase by about 14% compared to a set of medical devices not subject to the policy. Two are possible drivers of the increase in delays. The first is related to the fact that contracts awarded by national or regional agencies typically attract external bidders who are then further away from the health unit. The second one is that after the policy we observe a lower number of supplier per health unit; these suppliers are then more capacity constrained. We find evidence in favor of this second hypothesis.

AutorInnen

Adriano De Leverano, ZEW Mannheim

Decio Coviello, HEC Montreal

Robert Clark, Queen's University