Abstract
BackgroundCompetition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. The reform involved patient choice of provider, free establishment of new providers and a bundled payment model. The study aimed to examine its effects on hip replacement surgery quality as captured by patient reported outcome measures (PROMs) of health gain (as indicated by the EQ-5D index and a visual analogue scale (VAS)), pain reduction (VAS) and patient satisfaction (VAS) one and six years after the surgery.MethodsUsing patient-level data collected from multiple national registers, we applied a quasi-experimental research design. Data were collected for elective primary total hip replacements that were carried out between 2008 and 2012, and contain information on patient demography, the surgery and PROMs at baseline and at one- and six-years follow-up. In total, 36,627 observations were included in the analysis. First, entropy balancing was applied in order to reduce differences in observable characteristics between treatment groups. Second, difference-in-difference analyses were conducted to eliminate unobserved time-invariant differences between treatment groups and to estimate the causal treatment effects.ResultsThe entropy balancing was successful in creating balance in all covariates between treatment groups. No significant effects of the reform were found on any of the included PROMs at one- and six-years follow-up. The sensitivity analyses showed that the results were robust.ConclusionsCompetition and bundled payment had no effects on the quality of hip replacement surgery as captured by post-surgery PROMs of health gain, pain reduction and patient satisfaction. The study provides important insights to the limited knowledge on the effects of competition and economic incentives on PROMs.
Highlights
Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery
The present study aims to examine the effects of competition and bundled payment on the perceived quality of elective hip replacement surgery as captured by patient reported outcome measures (PROMs) of health gain, pain reduction and patient satisfaction one and 6 y after the surgery
For the one-year follow-up PROMs, a total of 36,627 observations were included in the analysis (Fig. 1), of which 6563 were from Stockholm (1143 and 5420 observations pre respectively post the reform) and 30,064 were from the other regions (4785 and 25,279 observations pre respectively post the reform)
Summary
Competition-promoting reforms and economic incentives are increasingly being introduced worldwide to improve the performance of healthcare delivery. This study considers such a reform which was initiated in 2009 for elective hip replacement surgery in Stockholm, Sweden. Patient choice policies promoting fixed-price competition among providers have been a popular approach in the Northern European countries where arguments for choice have been increased efficiency, responsiveness to quality and flexibility, as well as patient empowerment [3]. Provider payment models have been reformed to reward efficiency and quality in many OECD-countries. Examples of such innovations include pay-for-performance schemes and bundled payment arrangements where providers are given economic incentives to improve their performance [8]. The effects of various payment models on the performance have previously been investigated and findings from these studies are inconclusive [9,10,11]
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