What is the long term impact of voucher scheme on primary care? Findings from a repeated cross sectional study using propensity score matching

Carrie H K Yam,Eliza L Y Wong,Valerie L H Fung,Eng-Kiong Yeoh,Sian M Griffiths

doi:10.1186/s12913-019-4707-8

Carrie H K Yam, Eliza L Y Wong + Show 3 more

Open Access

https://doi.org/10.1186/s12913-019-4707-8

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Abstract

BackgroundVouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services. Elderly Healthcare Voucher Scheme has been introduced by the Hong Kong Government since 2009 to provide subsidy to elderly aged 65 and above to visit ten different types of private primary care providers for curative, preventive and chronic disease management. Several enhancements have been made over the past few years. This paper (as part of an evaluation study of this unique healthcare voucher scheme) aims to assess the long term impact of the voucher scheme in encouraging the use of primary care services.MethodsTwo rounds of cross-sectional survey among elderly in Hong Kong were conducted in 2010 and 2016. Propensity score matching and analysis were used to compare changes in perception and usage of vouchers over time.Results61.5% of respondents in 2016 agreed “the scheme encourages me to use more private primary care services”, a significant increase from 36.2% in 2010. Among those who agreed in 2016, the majority thought the voucher scheme would encourage them to use acute services (90.3%) in the private sector, rather than preventive care (40.3%) and chronic disease management (12.2%). Respondents also reported that their current usual choice of care was visiting “both public and private doctors” (61.9%), representing a significant increase (up from 48.4%) prior to their use of voucher.ConclusionsThe voucher scheme has encouraged the use of more private care services, particularly acute services rather than disease prevention or management of chronic disease. However, there needs to be caution that the untargeted and open-ended nature of voucher scheme could result in supply-induced demand which would affect long term financial sustainability. The dual utilization of health services in both the public and private sector may also compromise continuity and quality of care. The design of the voucher needs to be more specific, targeting prevention and chronic disease management rather than unspecified care which is mainly acute and episodic in order to maximize service delivery capacity as a whole for equitable access in universal health coverage and to contribute to a sustainable financing system.

Highlights

Vouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services
Hong Kong shares the health system characteristics of many other Asian health systems, considering the global need to identify innovative ways to build a sustainable health financing system, this study aims to provide important insight and greater understanding of drivers for use of the voucher scheme to achieve the objective of encouraging greater use of private primary care services and effectively managing chronic conditions amongst the elderly population in the community
In Hong Kong the voucher system for the elderly population has not enhanced the utilization of primary care for prevention and maintenance of chronic conditions within a community setting due to its unspecified design

Summary

Introduction

Vouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services. Is the elderly population growing, the globalization of unhealthy lifestyles has resulted in the rise of long-term chronic conditions and preventable illnesses requiring multiple complex health and social care interventions over many years [3]. This places greater pressure on both primary and secondary care services [4, 5]. In order to address the challenges, health systems around the world are increasingly orienting resources towards primary care and a community-based model of chronic care placing emphasis on better integration of services at both vertical and horizontal levels to improve the continuity and quality of care for frail elderly persons and patients with chronic diseases and to reduce the need for hospital admission [7]. Interventions that change resources, facilities or processes are necessary in shifting towards more outpatient and ambulatory services through investment in home care, nursing homes and hospices; repurposing hospitals for acute complex care only; and ambulatory facilities for day surgery, chronic facility-based care, and day hospital

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