Wohlin Jonas, Fischer Clara, Carlsson Karin Solberg, Korlén Sara, Mazzocato Pamela, Savage Carl, Stalberg Holger, Brommels Mats
Accumbo AB, SE-39230, Kalmar, Sweden.
Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden.
BMC Health Serv Res. 2021 May 1;21(1):406. doi: 10.1186/s12913-021-06392-6.
New Public Management (NPM) has been widely used to introduce competition into public healthcare. Results have been mixed, and there has been much controversy about the appropriateness of a private sector-mimicking governance model in a public service. One voice in the debate suggested that rather than discussing whether competition is "good" or "bad" the emphasis should be on exploring the conditions for a successful implementation.
We report a longitudinal case study of the introduction of patient choice and allowing private providers to enter a publicly funded market. Patients in need of hip or knee replacement surgery are allowed to choose provider, and those are paid a fixed reimbursement for the full care episode (bundled payment). Providers are financially accountable for complications. Data on number of patients, waiting lists and times, costs to the public purchaser, and complications were collected from public registries. Providers were interviewed at three points in time during a nine-year follow-up period. Time-series of the quantitative data were exhibited and the views of actors involved were explored in a thematic analysis of the interviews.
The policy goals of improving access to care and care quality while controlling total costs were achieved in a sustained way. Six themes were identified among actors interviewed and those were consistent over time. The design of the patient choice model was accepted, although all providers were discontent with the level of reimbursement. Providers felt that quality, timeliness of service and staff satisfaction had improved. Public and private providers differed in terms of patient-mix and developed different strategies to adjust to the reimbursement system. Private providers were more active in marketing and improving operation room efficiency. All providers intensified cooperation with referring physicians. Close attention was paid to following the rules set by the purchaser.
The sustained cost control was an effect of bundled payment. What this study shows is that both public and private providers adhere long-term to regulations by a public purchaser that also controls entrance to the market. The compensation was fixed and led to competition on quality, as predicted by theory.
新公共管理（NPM）已被广泛用于将竞争引入公共医疗保健领域。结果喜忧参半，对于在公共服务中模仿私营部门的治理模式是否合适存在诸多争议。辩论中的一种观点认为，与其讨论竞争是“好”还是“坏”，不如将重点放在探索成功实施的条件上。
我们报告了一项关于引入患者选择并允许私立医疗机构进入公共资助市场的纵向案例研究。需要进行髋关节或膝关节置换手术的患者可以选择医疗机构，并且针对整个护理过程会支付固定的报销费用（捆绑支付）。医疗机构要对并发症承担经济责任。从公共登记处收集了患者数量、等候名单和时间、公共采购方的成本以及并发症等数据。在为期九年的随访期间，对医疗机构进行了三次访谈。展示了定量数据的时间序列，并在对访谈的主题分析中探讨了相关行为者的观点。
在持续控制总成本的同时，实现了改善医疗服务可及性和医疗质量的政策目标。在接受访谈的行为者中确定了六个主题，并且这些主题随时间保持一致。尽管所有医疗机构都对报销水平不满，但患者选择模式的设计得到了认可。医疗机构认为质量、服务及时性和员工满意度有所提高。公立和私立医疗机构在患者组合方面存在差异，并制定了不同的策略来适应报销系统。私立医疗机构在营销和提高手术室效率方面更为积极。所有医疗机构都加强了与转诊医生的合作。密切关注遵循采购方制定的规则。
持续的成本控制是捆绑支付的结果。本研究表明，公立和私立医疗机构长期遵守公共采购方的规定，而公共采购方也控制着市场准入。正如理论所预测的那样，补偿是固定的，从而引发了质量方面的竞争。
