Independent Treatment Centres Are Not a Guarantee for High Quality and Low Healthcare Prices in The Netherlands – A Study of 5 Elective Surgeries

Abstract

Background: Independent treatment centres (ITCs) are a growing phenomenon in many healthcare systems. Focus factory theory predicts that ITCs provide high quality healthcare with low prices, through specialisation, high-volume and routine. This study examines if ITC care outperforms general hospital (GH) care within a regulated competition system in the Netherlands, by focusing on differences in healthcare quality and price. Methods: The cross-sectional study combined publicly available quality data, list prices and insurer contracts for 2017. Clinical outcomes of 5 elective surgeries (total hip and knee replacement, anterior cruciate ligament (ACL), cataract and carpal tunnel surgeries) were compared using zero-or-one inflated beta-regressions, corrected for underlying structural factors (ie, volume of care, process and structure indicators, and chain affiliation). Furthermore, price differences between ITCs and GHs were examined using ordinary least squares regressions. Lastly, we analysed quality of care in relation to the number of insurance contracts of the 4 largest Dutch insurance companies using ordered logistic regressions. Results: Quality differences between ITCs and GHs were found to be inconsistent across procedures. No facility type performed better overall. There were no differences exhibited in the list prices between ITCs and GHs. No consistent relationship was found between the underlying factors and quality or price, in different procedures and time. We found no indication for selective contracting based on quality within the ITC sector. Conclusions: This study found no evidence that ITCs outperform GHs on quality or price. This evidence does not support the focus factory theory. The substantial practice variation in quality of care may justify more evidence-based contracting within the market for elective surgery.

As predicted by theory: choice and competition in a publicly funded and regulated regional health system yield improved access and cost control

“…Despite these differences in strategies, conclusions regarding differences as to financial performance between private and public providers could not be drawn, as providers were not requested to report actual cost data to the purchasers, and annual financial statements did not include information of the profitability of service lines. But figures on operational efficiency (OR capacity use) did show that private focused factories were at an advantage, in line with the observations of Kruse et al [ 17 ] on cataract surgery, but not generalisable across procedure categories [ 18 ]. The results also showed greater responsiveness to the incentive structures of the model among private providers, a finding also reported by others [ 19 ].…”

A systematic review of the accessibility, acceptability, safety, efficiency, clinical effectiveness, and cost-effectiveness of private cataract and orthopedic surgery clinics

“…Access to health care is defined as the extent to which financial, organizational, geographical, and cultural barriers are minimized for patients (44). Eleven papers from the UK, Australia, Denmark, Canada, Netherlands, and Italy discussed the accessibility of services for cataract, hip, and knee patients and compared the private and public provision of these surgical procedures (7;12;15–18;31;33;34;39;41). Among these studies, only two (33;34) looked at accessibility related to patient preoperative/ general health status or symptom severity, and neither reached a definite conclusion about the relevance of these factors.…”

“…Clinical effectiveness can be assessed by many outcomes, such as improvements life-years gained, symptom relief, patient-reported outcomes, or cure. Researchers explored postoperative outcomes, readmission rates, reoperation rates, or short-term complications of surgical procedures as a clinical effectiveness factor in eight studies (6; 8;10;11;13;18;33;42). The most extensive research on the correlation between clinical effectiveness and care provider types was conducted in the UK (8;10;11) and Australia (6;13;33;42).…”

“…Efficiency refers to how to use resources effectively to achieve an objective (47). Surgical service efficiency was examined in ten studies (4;9;15;18;19;31;36;38–40). Most of the research adopted the technical efficiency perspective, so the authors evaluated length of stay (LOS), defined as from admission to discharge or preoperative only (4;9;15;36;39), and a number of the surgical procedures completed in a year (15;19;38).…”

“…Four papers from Australia, Denmark, and Netherlands discussed the accessibility of services for cataract patients and compared the private and public provision of these surgical procedures (17;18;33;34). Among these studies, only two (33;34) looked at accessibility related to patient preoperative/ general health status or symptom severity, and neither reached a definite conclusion about the relevance of these factors.…”