Vortragssitzung
Competition and Choice
Vorträge
Competition and prescribing behaviour in primary care
David Simón Jonathan Anchu Probst, Leibniz Universität Hannover | Institut für Gesundheitsökonomie
Einleitung / Introduction
Family doctors play a prominent role in almost all health care systems: they are the first point of contact in the event of illness and act as gatekeepers in the allocation of patients to secondary care. Yet, in comparison to the rich literature on the effect of competitive environments on hospitals, evidence on general practitioner behavior in a competitive setting is more sparse. This paper contributes to narrowing the research gap by examining the relationship of general practitioner prescribing behavior in an increasingly competitive environment.
Methode / Method
We use publicly available data to construct an (unbalanced) panel covering more than 7000 family doctor (general practitioner (GP)) practices in England between 2015 to 2020 (21 calendar quarters). Our data include a rich set of covariates, such as detailed physician and patient characteristics as well as practice-specific disease prevalences, as well as precise data on pharmaceutical prescribing. Competition is measured by a weighted Herfindahl-Hirschman Index. Following the hospital competition literature, we address potentially endogeneity concerns between quality of prescribing and market shares by basing our competition metric on predicted rather than observed patient flows.
Ergebnisse / Results
Our results indicate that an increase in competition among general practitioners may yield unintended consequences from a patient-centered as well as a societal perspective: increased competitive pressures result in increases in the number of prescriptions, which may not be medically indicated and would not have been prescribed, if the market for family doctors were less competitive. This change in prescribing style not only poses a potential threat to patient health, but also represents a burden on the taxpayer, who ultimately pays for the cost of excess prescriptions issued. For example, an increase in competitive pressure by 10 percent increases total over-the-counter (“OTC”) prescriptions by 31 (p< 1 %) prescriptions issued per practice. From a theoretical perspective, the phenomenon we observe can be explained by the concept of “perceived quality competition” as well as norm theory stemming from behavioral economics/psychology. While the existing literature on GP competition is sparse, it is in line with our results. A distinctive feature of our research is the derivation of causal inferences and a broader focus, taking into consideration a family doctor’s entire patient list.
AutorInnen
Annika Herr, Leibniz Universität Hannover | Institut für Gesundheitsökonomie
Nils Gutacker, University of York | Centre for Health Economics
David Probst, Leibniz Universität Hannover | Institut für Gesundheitsökonomie
Public reporting of quality and quality improvement in Germany’s hospitals
Esra Eren Bayindir, Universität Hamburg- Hamburg Center for Health Economics
Einleitung / Introduction
Hospital quality has been measured and made publicly available for over a decade in Germany to achieve quality improvement by enabling (1) informed hospital choice to boost quality competition and (2) structured dialogue with the hospitals with inferior quality. However, quality has improved very slowly for some indicators and has stagnated or even declined for some indicators in Germany’s hospitals.
Methode / Method
We used publicly available outcome indicators from structured hospital quality reports between 2012 and 2019 to assess hospital quality improvement in Germany. We considered pneumonia, heart, carotis, obstetrics, neonatology, decubitus, hip, and knee indicators. We tested whether hospitals used federal averages of the indicators as a benchmark. Furthermore, we examined the relationship between the change in the quality indicators and the quality quartile of the hospitals controlling for changes in the hospital (and department) characteristics and year fixed effects. We allowed the relationship between change in quality and quality quartile of the hospitals to differ for monopolists, best hospitals in oligopolies and ordinary hospitals (neither monopolists nor the best hospitals of their markets). Moreover, we used a difference-in-difference framework to examine the effect of competition (entry to monopoly) on quality.
Ergebnisse / Results
Quality has improved for hip and knee indicators, stagnated for obstetrics and neonatology indicators and deteriorated for pneumonia, decubitus, heart, and carotis indicators. Hospitals use the federal averages of quality indicators for benchmarking. On average, quality of the hospitals with low quality (lowest quartile) improved for all of the indicators, whereas the quality deteriorated for the hospitals with above average quality. Among ordinary hospitals, quality of the high quality hospitals decreased the most. Among the hospitals with high quality of care, quality of the best hospitals of their markets declined less than ordinary hospitals for heart, carotis, and knee indicators whereas the difference was not significant for the rest of the indicators we considered. Entry to monopoly led to quality improvement for carotis and pneumonia indicators and decline in quality for decubitus and obstetrics indicators.
Zusammenfassung / Conclusion
Public reporting provides a benchmark for hospitals and prevents provision of very low quality health care services. Preserving the good reputation of hospitals seems to be an important motivation for the best hospitals for some indicators (carotis, heart and knee indicators). However, competition among hospitals does not ensure quality improvement for most of the considered indicators. Therefore, relying on public reporting and market forces is not sufficient to achieve quality improvement in Germany’s hospitals.
AutorInnen
Esra Eren Bayindir, Universität Hamburg- Hamburg Center for Health Economics
Jonas Schreyögg, Universität Hamburg- Hamburg Center for Health Economics
Too many cooks could spoil the broth: Reducing choice overload under free provider choice by the coordination of health care
Christoph Strumann, UNIVERSITÄTSKLINIKUM Schleswig-Holstein, Campus Lübeck, Institut für Allgemeinmedizin
Einleitung / Introduction
Patient empowerment calls for an intensified participation of (informed) patients with more treatment opportunities to choose from. A growing body of literature argues that confronting consumers with too many opportunities can lead to a choice overload (CO) resulting in uncertainty that the selected alternative dominates all other options in the choice set. We examine whether there is a CO effect in the demand for ambulatory health care in Germany by analyzing the association of medical specialists supply on so-called patients' health uncertainty. Further, we investigate if patients’ health uncertainty could be reduced through the coordination by general practitioners (GPs) which materializes in the sequential elimination of treatment options and the provision of tailored information. In addition and going beyond the description of associative relations, the elimination of the German copayment system is used to uncover a causal channel linking an effectively extended patients’ choice set and health uncertainty.
Methode / Method
The empirical analysis conditions upon more than 37,000 observations on individual health and health behavior data from five waves of the German Socio-Economic Panel (SOEP) combined with health care infrastructure data at regional resolution. We apply the "within-between" formulation of Mundlak (1978) to analyze the association between health care infrastructure and health uncertainty. Further, we take advantage of the elimination of the German copayment system, which has weakened the coordinating role of GPs due to changes of the health care utilization behavior. The causal interpretation of the copayment elimination effect is obtained by applying a combination of Difference-in-Difference (DiD) analysis and statistical matching based on entropy balancing.
Ergebnisse / Results
We find that patients who live in an area with a large supply of specialists are subject to a CO effect that is expressed by an increased health uncertainty, and that CO effects can be traced back to the elimination of the copayments. The coordinating role of GPs seems to be effective to reduce the CO effect, while preserving free consumer choice.
Zusammenfassung / Conclusion
Our results suggest a choice overload effect in the demand for ambulatory health care in Germany. Patients that are confronted with a large choice set of available treatment alternatives and physicians have a reduced confidence in having selected the dominant specialized treatment from the set of alternative providers. The coordinating role of the GP has the scope to guide patients through the decision making process and to reduce the patients’ health uncertainty. Moreover, we provide evidence that the former copayment system for ambulatory care has been an effective policy influencing the patients’ behavior towards firstly visiting a general practice.