Which patients receive surgery in for-profit and non-profit hospitals in a universal health system? An explorative register-based study in Norway.

OBJECTIVES: To compare the socioeconomic status (SES) and case-mix among day surgical patients treated at private for-profit hospitals (PFPs) and non-profit hospitals (NPs) in Norway, and to explore whether the use of PFPs in a universal health system has compromised the principle of equal access regardless of SES. DESIGN: A retrospective, exploratory study comparing hospital types using the Norwegian Patient Register linked with socioeconomic data from Statistics Norway by using Norwegian citizens' personal identification numbers. SETTING: The Norwegian healthcare system. POPULATION: All publicly financed patients in five Norwegian metropolitan areas having day surgery for meniscus (34 100 patients), carpal tunnel syndrome (15 010), benign breast hypertrophy (6297) or hallux valgus (2135) from 2009 to 2014. PRIMARY OUTCOME MEASURE: Having surgery at a PFP or NP. RESULTS: Across four unique procedures, the adjusted odds ratios (aORs) for using PFPs were generally lower for the lowest educational level (0.77-0.87) and the lowest income level (0.68-0.89), though aORs were not always significant. Likewise, comorbidity and previous hospitalisation had lower aORs (0.62-0.95; 0.44-0.97, respectively) for having surgery at PFPs across procedures, though again aORs were not always significant. No clear patterns emerged with respect to age, gender or higher levels of income and education. CONCLUSIONS: The evidence from our study of four procedures suggests that equal access to PFPs compared with NPs for those patients at the lowest education and income levels may be compromised, though further investigations are needed to generalise these findings across more procedures and probe causal mechanisms and appropriate policy remedies. The finding that comorbidity and previous hospitalisation had lower odds of treatment at PFPs indicates that NPs play an essential role for more complex patients, but raises questions about patient preference and cream skimming.

Outsourcing day surgery to private for-profit hospitals: the price effects of competitive tendering.

Setting prices for elective patient treatments in private for-profit (PFP) hospitals in traditional tax-funded health systems is challenging since both the organisation of these hospitals and the tasks they perform differ considerably from what we find in public hospitals. From the year 2000, Norway became one of a few countries to gradually implement a procurement system based on competitive tendering when outsourcing elective surgery. In this study we analyse the effect of introducing competitive tendering on the prices paid to PFP hospitals. Pricing data were collected from the formal contracts awarded to PFP hospitals and defined in terms of both absolute and relative prices. We found that PFP hospitals performed day surgeries at markedly lower prices than public hospitals and that competitive tendering triggered the price reduction. We speculate that the PFP hospitals' lack of acute services, less severe patient population, reduced teaching responsibilities and ability to streamline production, as well as other factors, explain the lower prices at PFP hospitals.

Quality differences between private for-profit, private non-profit and public hospitals in Norway: a retrospective national register-based study of acute readmission rates following total hip and knee arthroplasties.

OBJECTIVES: To compare the quality of care-using unplanned acute hospital readmissions as a quality measure-among patients treated at private for-profit hospitals (PFPs), private non-profit hospitals (PNPs) and public hospitals (PUBs) in Norway. DESIGN: A retrospective comparative study using the Norwegian Patient Register. Readmissions were evaluated by logistic regressions both using adjustment for various patient-level and other covariates, and a two-stage model using distance as an instrumental variable. SETTING: The Norwegian healthcare system. POPULATION: All publicly financed patients having primary total hip (37 897 patients) or primary total knee arthroplasty (25 802 patients) at one of the three hospital types from 2009 to 2014. PRIMARY OUTCOME MEASURE: 30-day unplanned acute hospital readmission rate. RESULTS: We found highest readmission rates among PUBs and lowest among PFPs, for both procedures. However, the patients were on average more than 2 years younger at PFPs. PFPs also treated the least severe patients, while PUBs treated the most severe. Using adjustment for various patient-level and other covariates, compared to PUBs, both PFPs and PNPs had lower odds of readmission following both procedures. However, using the instrumental variable method, the only significant difference found was a lower odds of readmission at PNPs among hip patients when compared with PUBs. No patients in our data set were readmitted to PFPs, those originally treated at PFPs were readmitted to either PNPs or PUBs, and PUBs received most of the readmitted patients across hospital types. CONCLUSIONS: Quality differences between hospital types were small; however, PNPs had significantly lower readmission rates compared with PUBs among patients having total hip arthroplasty. PUBs received the larger part of the readmitted patients across hospital types and thus play an essential role in the care of more complex patients and for readmissions, regardless of any quality differences.