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PubMed1998

Changing the public-private mix: an assessment of the health reforms in Greece.

The 1983 health reform in Greece was a major political event in the social policy agenda. The main objective of the reform was the institution of a National Health System and the expansion of the health sector, improved equity, and the assumption of full responsibility for health services delivery by the state. An assessment of the results 10 years after full implementation of the reform shows that despite the expansion of the public sector, the public-private mix in financing and delivery has changed in favour of the private sector, making the Greek health system the most 'privatised' among the EU countries. The main reasons why the health reform failed to meet its objectives was the restrictive enforcement of full-time and exclusive hospital employment for doctors, the virtual ban on private hospital expansion, the much faster introduction and diffusion of new health technology by the private sector, and poor management, planning and control in the public sector. A new health reform voted into law in the summer of 1997 shows promise of redressing some of the shortcomings of the 1983 reform.

Administrative Personnel↗
PubMed2005

[A paradigm change in German academic medicine. Merger and privatization as exemplified with the university hospitals in Marburg and Giessen].

1. The intended fusion of the university hospitals Marburg and Giessen in the state of Hessia is "a marriage under pressure with uncalculated risk" (Spiegel 2005). In the present political and financial situation it hardly appears to be avoidable. From the point of the view of the faculty of medicine in Marburg it is difficult to understand, that the profits of this well guided university hospital with a positive yearly budget should go to the neighboring university hospital which still had a fair amount of deficit spending in the last years.2. Both medical faculties suffer from a very low budget from the state of Hessia for research and teaching. Giessen much more than Marburg, have a substantial need for investments in buildings and infrastructure. Both institutions have a similar need for investments in costly medical apparatuses. This is a problem, which many university hospitals face nowadays.3. The intended privatisation of one or both university hospitals will need sound answers to several fundamental questions and problems:a) A privatisation potentially endangers the freedom of research and teaching garanteed by the German constitution. A private company will undoubtedly influence by active or missing additional support the direction of research in the respective academic institution. An example is the priorisation of clinical in contrast to basic research.b) With the privatisation practical absurdities in the separation of research and teaching on one side and hospital care on the other will become obvious with respect to the status of the academic employees, the obligatory taxation (16%) when a transfer of labor from one institution to the other is taken into account. The use of rooms for seminars, lectures and bedside with a double function for both teaching, research and hospital care has to be clarified with a convincing solution in everyday practice.c) The potential additional acquisition of patients, which has been advocated by the Hessian state government, may be unrealistic, when the 4th biggest university hospital in Germany will be created by the merger. University hospitals recrute the patients for high end medicine beyond their region because of the specialized academic competence and advanced technical possibilities. Additional recruitment of patients for routine hospital can hardly be expected.d) A private management will have to consider primarily the "shareholder value", even when investing in infrastructure and buildings, as it can be expected for one partner. On the longterm this will not be possible without a substantial reduction of employees in both institutions. There are, however, also substantial efforts of some private hospital chains in clinical research, e. g. by Helios in Berlin and Rhön Gmbh at the Leipzig Heart Center.e) There is a yet underestimated but very substantial risk because of the taxation for the private owner when academic staff is transferred from the university to hospital care in their dual function as academic teachers and doctors. This risk also applies for the university if the transfer should come from hospital to the university. These costs would add to the financial burden, which has to be carried in addition to the DRGs.

Academic Medical Centers↗
PubMed1996

Beyond the public-private debate: the mixed economy of health.

Can or should private organisations provide public healthcare services? What is the scope for private finance in public healthcare services? This paper reviews some of the arguments for and against public or private ownership management and financing of public healthcare services. It concentrates on health services, where non-economic values and ethical questions are as important as the efficiency considerations, and on health purchasing or funding organisations. The paper describes the increasingly complex interrelationship and forms of competition between public and private providers, purchasers and financiers in the UK health sector. It argues that the simple private/public distinction never did describe well the many different forms of financing ownership and operation of health services in any country and is now a handicap to both scientific and lay policy debate about future options. It proposes a framework for describing the main forms of ownership and operations of health services and considers the future for health service purchasing and funding.

Contract Services↗
PubMed2006

Timing of scheduled cesarean delivery in patients on a teaching versus private service: adherence to American College of Obstetricians and Gynecologists guidelines and neonatal outcomes.

OBJECTIVE: The purpose of this study was to compare adherence to American College of Obstetricians and Gynecologists guidelines for the timing of scheduled cesarean delivery in patients of a resident teaching service and patients of a private service to determine the neonatal intensive care unit admission rate and the most frequent admission diagnoses after scheduled cesarean delivery and to compare neonatal outcomes between the groups. STUDY DESIGN: A retrospective cohort was reviewed by medical record at a tertiary care center. The cases of 609 patients who were delivered by scheduled cesarean delivery were reviewed, and 296 patients were included. Data regarding demographics, dating, delivery, and outcome were collected and compared with the use of statistical software. RESULTS: Significant differences were noted between patients of a teaching service and patients of a private service, with respect to patient age (26.9 vs 30.7 years; P < .001), body mass index (33.7 vs 31.9 kg/m2; P = .030), race (40.4% white patients in resident teaching services vs 86.0% white patients in private services; P < .001), primary elective cesarean delivery (4 vs 23 deliveries; P = .013), and adherence to American College of Obstetricians and Gynecologists guidelines for the timing of elective delivery (96.3% vs 62%; P < .001), with no significant difference in number of neonatal intensive care unit admissions, severity of neonatal disease, or length of stay in the neonatal intensive care unit. The overall neonatal intensive care unit admission rate for all deliveries by scheduled cesarean delivery was 3.7%. The most frequent neonatal intensive care unit admission diagnoses were hypoglycemia and transient tachypnea of the newborn infant, with no severe sequelae of prematurity in either group. When controlled for fetal anomalies and infants who were born to pregestational diabetic mothers, no significant differences in number of admissions or outcomes were noted; however, 50% of the admissions to the neonatal intensive care units in both groups resulted from violations in American College of Obstetricians and Gynecologists criteria. CONCLUSION: The overall neonatal intensive care unit admission rate after scheduled cesarean delivery in this study is consistent with that reported in the neonatology literature. Patients of a teaching service were a demographically different group than those on the private service, were less likely to get an elective primary cesarean delivery, and were more likely to be delivered in adherence to American College of Obstetricians and Gynecologists guidelines, although this did not significantly affect the rates of admission to the neonatal intensive care unit or neonatal outcome.

Adolescent↗
PubMed2004

Sharing the spirit of the policy agenda? Private complementary therapists' attitudes towards practising in the British NHS.

During recent years, complementary medicine (CM) has grown as a significant provider of health care in the UK, the majority of this provision being allocated through the small private business sector to privately paying clients. Given the substantial demand for CM, the government acknowledges its structural integration with orthodox medicine (OM) to be a logical progression. However, although the time frame, evidence bases and regulatory structures are as yet undetermined, key to the current emphasis on integration is an underlying assumption that private sector providers would be willing participants, potentially alongside nurses. In this context, using a combined questionnaire (n=426) and interview (n=49) survey, this paper makes an initial exploration and considers the current connections that private therapists have with OM and their attitudes towards collaborating with and working within the NHS. The majority of therapists claimed not to have existing business connections with NHS providers, though many stated that they had established some form of informal arrangements. In general, therapists were happy that they had experienced increasingly positive reactions from orthodox clinicians towards their therapies. The overwhelming majority of therapists were positive about the proposition of working within OM but did have certain reservations. Given the range and intensity of opinion found in this initial investigation, the paper concludes by signposting some substantive avenues of focused research inquiry on the structural integration of CM and OM.

Adult↗
PubMed2006

The role of job satisfaction, job dissatisfaction and demographic factors on physicians' intentions to switch work sector from public to private.

This study is based on a unique data set for the years 1988-2003 and uses structural equation models to examine the impact of job satisfaction and job dissatisfaction on physicians' intention to switch from public- to private-sector work. In Finland, physicians who work primarily in a public-hospital or health-centre setting can also run a private practice. Therefore, we also analysed the impact of having a private practice on a physician's intention to change sector. We found that private practice had a positive, statistically significant effect on the intention to switch sector in 1998 and 2003. Results also suggest that job satisfaction decreases a physician's intention to switch sector, although for 1998 it had no effect. Surprisingly, job dissatisfaction significantly increased the physicians' intentions to leave the public sector only in the 1988 data.

Career Mobility↗
PubMed2005

Treatment-seeking behaviour in urban Sri Lanka: trusting the state, trusting private providers.

Trust is central to good relationships between patients and health-care providers because, firstly, patient uncertainty about health conditions requires them to have confidence in a doctor's motives and decisions, and secondly, trust facilitates communication and patient focus which encourages people to utilise health services. This paper focuses on patient trust because of its effect on treatment-seeking behaviour and the treatment costs incurred by poor households. Drawing from other studies the paper distinguishes between trust based on the perceived technical competence of the provider, and on inter-personal dimensions of quality of care. Trust is also analysed at two inter-related levels: personal trust that is built through face-to-face encounters with providers; and more abstract institution-level trust. The paper applies these notions of trust to examine treatment-seeking behaviour in two poor urban communities in Colombo, Sri Lanka. Household survey data and qualitative data show that people from a range of income groups preferred to use public providers for more serious illnesses because public services were free and they trusted the technical competence of public providers at both a personal and institutional level. The data also show, however, that inter-personal quality of care was lacking in the public sector and that residents from the two communities, including a considerable minority of the poorest, preferred to use private providers for moderate acute illnesses. People were willing to pay for private services because it saved time, doctors listened and they could build better relationships with private doctors. Despite the strengths of Sri Lanka's public health sector, poor relationships act as an access barrier and push a range of income groups to the private sector. The threat to access and affordability posed by these poor relationships should be the focus of current reform debates.

Delivery of Health Care↗
PubMed2005

Access to urologic care for children in California: Medicaid versus private insurance.

OBJECTIVES: To compare the access to urologic care for a child with cryptorchidism insured by Medi-Cal versus one insured by private insurance. Medi-Cal (California State Medicaid) is a joint state and federal health insurance program that plays a significant role in providing healthcare coverage to low-income children. METHODS: A total of 54 randomly chosen urology offices throughout California were surveyed by telephone to determine whether the office accepted pediatric patients, accepted Medi-Cal, and when the earliest appointment date would be for a patient with Medi-Cal versus one with private insurance. RESULTS: Of the 46 practices that accepted pediatric patients, 96% offered a new patient appointment to a child with private insurance, but only 41% were willing to offer an appointment to a child with Medi-Cal (P < 0.0001). Of the offices that would not see a child with Medi-Cal, 75% were unable to recommend a urology office that might accept Medi-Cal. CONCLUSIONS: Children insured by Medi-Cal have significantly less access to necessary urologic care compared with children with private insurance.

California↗
PubMed2002

Multiple payers, commonality and free-riding in health care: Medicare and private payers.

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US.

Consumer Behavior↗
PubMed2001

Patients receiving immunotherapy report it is effective as assessed by the rhinitis outcomes questionnaire (ROQ) in a private practice setting.

BACKGROUND: Outcomes measurement is a proficient method in determining the effectiveness of medical therapy. Currently, there are no easy-to-use and inexpensive questionnaires available to evaluate the effectiveness of immunotherapy by allergists in private practice. OBJECTIVE: To evaluate the effectiveness of immunotherapy in the treatment of patients with allergic rhinitis in a private practice setting using the rhinitis outcomes questionnaire (ROQ). METHODS: One hundred seventy-five patients were randomly chosen from three private practices nationwide. They were surveyed regarding global systemic problems and nasal, eye, and chest symptoms, as well as their medical treatment history. This questionnaire was administered twice in one sitting, with the first a recall of symptoms before immunotherapy treatment, and the second an evaluation of current symptoms. RESULTS: The data revealed that 81% of the patients believed immunotherapy worked, with 19% unsure. Patients experienced a 67% decrease in antibiotic use, a 68% decrease in emergency room visits, a 75% decrease in days lost from work or school, and a 79% decrease in hospital admissions. The average symptom score reduction with immunotherapy was 52%. CONCLUSIONS: This study demonstrates that the user-friendly ROQ can be effectively and inexpensively used in a private practice setting and that immunotherapy is effective in the treatment of allergic rhinitis.

Female↗
PubMed2003

Public-private mix DOTS in the Philippines.

The National Tuberculosis Prevalence Survey done in 1997 (1997 NPS) revealed that the magnitude of tuberculosis in the Philippines hardly declined between 1982 and 1997. In 1996, the National TB Control Program (NTP) adopted the directly observed treatment short-course (DOTS) strategy. By the end of 2001, more than 90% of the population have access to it. Cohort analysis revealed good treatment outcomes. Despite this improvement in the public sector, there is a concern that the epidemiological impact of DOTS will be limited due to the non-participation of the private practitioners, a major stakeholder. Public-private sector collaboration in TB control was strengthened since the Philippine Coalition Against TB (PhilCAT) was organized in 1994. There are four areas of collaboration, namely, policy development, advocacy and information dissemination, training and research and service delivery. Four models of public-private mix (PPM) DOTS in service delivery were developed. The private DOTS clinics provide the space, staff and operational funds while the Department of Health (DOH) provided technical assistance, anti-TB drugs, laboratory supplies and forms. Evaluation showed that PPM in TB control is feasible with good results. The major challenge is to replicate and institutionalize the PPM DOTS.

Communicable Disease Control↗
PubMed1999

Privatized biomedical research, public fears, and the hazards of government regulation: lessons from stem cell research.

This paper discusses the hazards of regulating controversial biomedical research in light of the emergence of powerful, multi-national biotechnology corporations. Prohibitions on the use of government funds can simply force controversial research into the private sphere, and unilateral or multilateral research bans can simply encourage multi-national companies to conduct research in countries that lack restrictive laws. Thus, a net effect of government regulation is that research migrates from the public to the private sphere. Because private research receives less oversight and external scrutiny than public research, it can threaten the welfare and rights of human subjects, scientific progress and openness, and the quality of the approval process for new biomedical technologies. In order to avoid the harmful effects of government regulation of biotechnology, society should promote meaningful discussion and dialogue among scientists, industry leaders, and the public before resorting to regulatory solutions. Legislative or executive initiatives should be applied with great discretion and care, and should be crafted in such a way that they protect public health and safety, promote scientific progress, and avoid the hazards of privatized research and polarized debates.

Biotechnology↗
PubMed1999

Patient satisfaction in Turkey: differences between public and private hospitals.

This article reports the results of a patient-satisfaction survey administered by interview to 2045 adults discharged from several major public and private hospitals in Turkey. The direct measurement of patient-satisfaction is a new phenomenon for this country. An instrument was designed similar to those available in the United States and administered during exit interviews. Two primary areas of analyses were determined in comparing services provided by these public and private hospitals: demographic factors with regard to accessibility and consumer perceptions of the quality of service provided. Relationships and percentages within and among the five public and two private hospitals are reported. Several statistically significant differences were found between the hospitals, with the private hospitals achieving the greatest satisfaction on most of the quality of services issues examined. Future recommendations outline the need to take into account the public's perception of these hospitals and enhancing customer satisfaction as a means of increasing service utilization.

Adolescent↗
PubMed2004

Perceptions of livestock owners of private veterinary practice in Ghana.

Using the participatory appraisal approach, a study was designed to assess the perceptions of livestock owners on private delivery of veterinary services in two districts in the major livestock-producing area in Ghana. A significant proportion (74%, n = 180) were willing to patronize locally established veterinary practices. However, the respondents emphasized that the fees charged had to be reasonable and affordable. Factors identified as likely to discourage the use of the private provider included the inability of the provider to speak the local language; non-availability of credit facilities for services rendered by the provider; unreliability of personnel; poor interpersonal skills; lack of technical know-how; inability of the provider to make house calls or farm visits; and poor personal and work ethics. These findings provide information for prospective private veterinarians on the expectations of their clients and could be used in the preparation of veterinarians for private practice.

Agriculture↗
PubMed2000

Influence of monopoly privatization and market liberalization on smoking prevalence in Japan: trends of smoking prevalence in Japan in 1975-1995.

AIMS: In Japan, smoking prevalence in males has been among the highest among industrialized countries, while the prevalence in females has remained relatively low. There have been long-term declining trends since the early 1970s. In the mid-1980s, the public tobacco monopoly was privatized and the tobacco market was liberalized in Japan. This study examines whether the trends in smoking prevalence changed at the time of these market changes. DESIGN AND MEASUREMENTS: Smoking prevalence data, tabulated by age group and sex, were plotted over the period 1975-95. Trends of smoking prevalence were then analyzed by using linear regressions, and their changes at the time of monopoly privatization and market liberalization were examined by Chow tests. FINDINGS: The trends in smoking prevalence changed at the time of the monopoly privatization and trade liberalization in both males and females, except for the males in their twenties and thirties. Rates of decline in smoking prevalence diminished in many age groups and prevalence for younger females started to increase. CONCLUSIONS: Market changes, that result from the privatization of a public tobacco monopoly and trade liberalization, may adversely affect smoking prevalence in many age groups and in both sexes, unless effective countermeasures are taken.

Adult↗
PubMed2003

Public-private partnerships in healthcare: the managers' perspective.

The role of the private sector in the provision of publicly funded healthcare services has become the subject of increasing debate and discussion at the heart of the New Labour Government. The present paper reports the findings from an empirical study regarding the attitude of public-sector managers towards public-private partnerships in the healthcare arena. It reveals a growing awareness amongst managers of both the positive and negative consequences of stepping into the market place to purchase services. However, in the context of the ongoing ideological debate within the Government regarding the role of both the private sector and markets within healthcare, public sector managers are unlikely to receive the practical advice that will enable them to reap the benefits of working with the private sector and avoid the pitfalls.

Attitude to Health↗
PubMed2000

Women's choice? The impact of private health insurance on episiotomy rates in Australian hospitals.

OBJECTIVE: To assess the extent to which variations in episiotomy rates in Australian hospitals are justified by clinical variables and to further explore the relationships between episiotomy, insurance status, perineal trauma and outcomes for babies. DESIGN: A retrospective analysis of anonymous medical record data using logistic regression models, aimed at identifying factors influencing both episiotomy rates and outcomes for babies. SETTING: A large regional public hospital, New South Wales, Australia. PARTICIPANTS: The study sample consisted of 2028 women who delivered vaginally during a 12 month period during 1996-1997. RESULTS: After controlling for clinical and other factors privately insured women were estimated to be up to twice as likely to experience episiotomy as publicly insured women. This difference most plausibly reflects differences in labour management styles between obstetricians and midwives. Other significant contributors to episiotomy were instrumental delivery, indications of possible fetal distress and lower parity. Severe perineal trauma (third degree tear) was found to be positively associated with episiotomy. Furthermore, the incidence of additional tears requiring suture was also substantially higher among privately insured women, the net effect being that these women had a substantially lower chance of achieving an intact perineum. Neither episiotomy nor insurance status had any significant effect on the well-being of babies. IMPLICATIONS FOR PRACTICE: Private health insurance appears to deny many women the opportunity of achieving normal vaginal delivery with intact perineum. Episiotomy rates amongst privately insured women in Australia may be higher than is clinically appropriate, and severe perineal trauma within this study was associated with this practice.

Decision Making↗
PubMed2002

Public hospitals: who's looking after you? The difficulties in encouraging patients to use their private health insurance in public hospitals.

Private health insurance (PHI) is an important part of the Australian health system. During the introduction of the recent PHI reforms it was argued that, without the reforms, the public hospital system would undoubtedly collapse under the increased demand for public health services. The increase in PHI coverage might also have been expected to result in an increase in the revenue earned by public hospitals as a result of treating privately insured patients. However, the decline in numbers of privately insured patients using their PHI in public hospitals has continued, with adverse impacts on public hospital budgets in some states. This article addresses the complex interactions between various policy instruments and their impact on public hospitals, and reports the results of a study conducted at the Austin & Repatriation Medical Centre (A&RMC) which examined the reasons for privately insured patients electing not to use their insurance in public hospitals, and methods by which they might be overcome.

Budgets↗