The Intersection of Private and Public Action in Health and Health Care Internationally
Friday, Jan. 3, 2020 10:15 AM - 12:15 PM
- Chair: Karen N. Eggleston, Stanford University
Private Hospital Responses to Reimbursement Changes under Insurance in India
AbstractAs achieving universal health coverage becomes a priority, governments in lower income countries are expanding public health insurance programs that target poor households and contract the private sector to deliver care. To contain costs while providing financial protection, many of these programs adopt bundled payment systems that reimburse hospitals a fixed rate per admission, adjusted for diagnosis and procedure, and require hospitals to provide free care. Under these systems, hospital reimbursement rates are a key policy lever to shape hospital incentives, with significant implications for service volumes, quality, patient selection, and health outcomes, but the evidence on their effects in lower income countries is limited. We provide new quantitative evidence on how private hospitals respond to changes in reimbursement rates in the context of a government health insurance program that entitles 46 million low-income individuals to free hospital care in Rajasthan, India. Exploiting a policy-induced natural experiment that increased hospital reimbursement rates by varying magnitudes across a range of services, and using administrative claims data linked to patient surveys for the 6 months prior to and 7 months following the policy change, we examine the effects of hospital reimbursement changes on hospital entry, service volumes, upcoding, and patient out-of-pocket expenses. We find that hospital participation increases and that there are changes in claim composition, largely related to changes in hospital upcoding behavior. We also find that hospitals capture some of the increased public reimbursements and that there are no meaningful changes in the socioeconomic and demographic composition of patients in the program. Our results can inform the design of public health insurance programs in weak contract enforcement environments as well as social and health programs that outsource delivery to the private sector.
Does Pay-for-Performance Improve Quality of Care? Evidence from Senegal
AbstractMany low-income countries have chosen to introduce pay-for-performance (P4P) schemes that link financial rewards to performance targets. Although many dimensions of providers’ effort are not contractible, such incentives are meant to increase quality of care, by increasing providers’ motivation and accountability. Despite the enthusiasm for P4P, the evidence about its effectiveness remains mixed. While some schemes have increased the volume of care provided and structural care quality, no study has looked at the impact of P4P on the process quality and effectiveness of care provided. This study aims to fill this gap, by measuring the impact of a P4P scheme on the quality and effectiveness of care for services that were rewarded and not rewarded.
We take advantage of a randomised pilot of P4P in Senegal to identify the impact of P4P on quality of care. In the pilot, primary care facilities randomised to the treatment received financial incentives linked to the volume and appropriateness of care for maternal, reproductive and child services. We conducted an audit study in 196 public primary care facilities, using unannounced standardised patients to collect objective measures of quality and effectiveness of care. SPs are healthy individuals trained to consistently portray a particular clinical case and to subsequently report the performance of the providers consulted against a checklist reflecting the national guidelines and essential recommended care. The use of SPs provides many advantages over other methods of assessing quality such as clinical observations, patient exit interviews or use of medical records. SPs are especially useful to provide comparisons across settings, without problems of patient selection. In this study, each facility was visited by five standardised patients: two portraying a condition that was incentivised by the scheme (family planning and child with dysentery) and three presenting conditions that were not incentivised (asthma, angina and tuberculosis).
Knowledge, Food Vouchers, and Child Nutrition: Evidence from a Field Experiment in Ethiopia
AbstractChildren in developing countries often consume diets of limited diversity, increasing their risk of chronic undernutrition. These monotonous diets are a consequence of many factors including poor maternal knowledge of child nutrition and limited resources. We implemented a clustered randomized control trial that randomly provides a nutrition education intervention (Behavior Change Communication, BCC) to improve maternal knowledge, food vouchers to address the income constraint, or both. We find a reduction in chronic child undernutrition only when both BCC and vouchers are provided, even though BCC alone improves mothers’ nutritional knowledge and child-feeding behaviors to some extent. Further, we find that BCC alone leads mothers to increase their self-employed farming labor supply to procure additional resources to support improved child-feeding practices. Food vouchers alone did not have any effect on mothers’ nutritional knowledge or child-feeding behaviors. Our results suggest that, when both knowledge and income are intertwined challenges for improved child-feeding practices, addressing both constraints simultaneously may augment the positive impacts.
University of Illinois-Chicago
Winnie Chi-Man Yip,
- I1 - Health
- P4 - Other Economic Systems