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

Document Type: Original Article

Authors

1 IQ healthcare, Radboud University and Medical Center, Nijmegen, The Netherlands

2 Ministry of Health, Welfare and Sport, The Hague, The Netherlands

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

Highlights

 

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Keywords


  1. Pammolli F, Riccaboni M, Magazzini L. The sustainability of European health care systems: beyond income and aging. Eur J Health Econ. 2012;13(5):623-634. doi:10.1007/s10198-011-0337-8
  2. Porter ME. Value-based health care delivery. Ann Surg. 2008;248(4):503-509. doi:10.1097/SLA.0b013e31818a43af
  3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:10.1377/hlthaff.27.3.759
  4. Christensen CM. The Innovator’s Prescription. New York: McGraw-Hill Education; 2009.
  5. Cassel CK. Can retail clinics transform health care? JAMA. 2018;319(18):1855-1856. doi:10.1001/jama.2018.2172
  6. Kelly E, Tetlow G. Choosing the place of care: the effect of patient choice on treatment location in England, 2003-2011. https://www.nuffieldtrust.org.uk/files/2017-01/choosing-place-of-care-web-final.pdf.   Accessed March 7, 2019. Publidhed 2012.
  7. NHS Digital. Hospital Outpatient Activity. 2010-2011. https://digital.nhs.uk/data-and-information/publications/statistical/hospital-outpatient-activity/hospital-outpatient-activity-2010-11#resources.   Accessed March 7, 2019.
  8. Inspectie Gezondheidszorg en Jeugd. Het resultaat telt: Particuliere klinieken 2016. Utrecht: IGJ; 2018. https://www.igj.nl/binaries/igj/documenten/rapporten/2018/04/03/het-resultaat-telt-particuliere-klinieken-2016/IGJ-HRT-klinieken-2016_05+DEF.PDF.   Accessed March 7, 2019.
  9. Vektis. Aandeel zelfstandige behandelcentra blijft toenemen. Vektis website. https://www.vektis.nl/nieuws/aandeel-zelfstandige-behandelcentra-blijft-toenemen.  Accessed March 7, 2019. Published 2018.
  10. Suskind AM, Zhang Y, Dunn RL, Hollingsworth JM, Strope SA, Hollenbeck BK. Understanding the diffusion of ambulatory surgery centers. Surg Innov. 2015;22(3):257-265. doi:10.1177/1553350614546004
  11. Monitor zelfstandige behandelcentra: een kwalitatieve en kwantitatieve analyse. Utrecht: NZa; 2012. https://www.zorgkennis.net/downloads/kennisbank/F4C-kennisbank-Monitor-zelfstandige-behandelcentra-817.pdf.  Accessed March 7, 2019.
  12. Marselis D. Zbc’s vieren porseleinen jubileum: 20 jaar verzekerde zorg in zelfstandige behandelcentra. https://www.ntvg.nl/artikelen/zbcs-vieren-porseleinen-jubileum.   Accessed March 4, 2019. Published 2019.
  13. Kruse FM. Focusklinieken en betaalbaarheid. In: Jeurissen PTT, Maarse H, Tanke M, eds. Betaalbare zorg. Sdu; 2018.
  14. Krabbe-Alkemade YJ, Groot TL, Lindeboom M. Competition in the Dutch hospital sector: an analysis of health care volume and cost. Eur J Health Econ. 2017;18(2):139-153. doi:10.1007/s10198-016-0762-9
  15. Heijink R, Mosca I, Westert G. Effects of regulated competition on key outcomes of care: cataract surgeries in the Netherlands. Health Policy. 2013;113(1-2):142-150. doi:10.1016/j.healthpol.2013.06.003
  16. Kroneman M, Boerma W, van den Berg M, Groenewegen P, de Jong J, van Ginneken E. Netherlands: health system review. Health Syst Transit. 2016;18(2):1-240.
  17. Nederlandse Zorgautoriteit (NZa). Monitor Zorgverzekeringen 2018. Utrecht: NZa; 2018.
  18. Nederlandse Zorgautoriteit (NZa). Marktscan en beleidsbrief: Medisch specialistische zorg. Weergave van de markt 2009-2013. Utrecht: NZa; 2013.
  19. Skinner W. The focused factory. https://hbr.org/1974/05/the-focused-factory.   Accessed March 7, 2019. Published 1974.
  20. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691-729.  doi:10.1111/j.1468-0009.2005.00397.x
  21. Herzlinger RE. Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America’s Largest Service Industry. New York: Perseus Books Group; 1997.
  22. Nederlandse Zorgautoriteit (NZa). Marktscan Medisch-specialistische zorg. Utrecht: NZa; 2016.
  23. Zorginstituut Nederland. Indicatorenset Cataract. https://www.zorginzicht.nl/bibliotheek/cataract/RegisterMeetinstrumentenDocumenten/Indicatorengids%20Cataract%202017.docx.   Accessed March 7, 2019. Published 2017.
  24. Zorginstituut Nederland. Indicatorgids TKP. https://www.zorginzicht.nl/bibliotheek/Knieprothese/RegisterMeetinstrumentenDocumenten/Indicatorgids_TKP.docx.   Accessed March 7, 2019. Published 2017.
  25. Zorginstituut Nederland. Indicatorgids Totale Heup Prothese. https://www.zorginzicht.nl/bibliotheek/Heupprothese/RegisterMeetinstrumentenDocumenten/Indicatorgids_Totale%20Heupprothese.docx.   Accessed March 7, 2019. Published 2017.
  26. Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):1304-1311. doi:10.1377/hlthaff.2014.1282
  27. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261(1):2-8. doi:10.1097/sla.0000000000000765
  28. Volksgezondheidenzorg.info. Locaties ziekenhuizen 2018. https://www.volksgezondheidenzorg.info/onderwerp/ziekenhuiszorg/regionaal-internationaal/locaties#bronverantwoording.  RIVM: Bilthoven. Accessed November 1, 2019. Published 2018.
  29. Vektis. Verzekerden in beeld 2018, Inzicht in het overstapseizoen. Zeist: Vektis; 2018. https://www.vektis.nl/uploads/Publicaties/Zorgthermometer/Zorgthermometer%20Verzekerden%20in%20Beeld%202018.pdf.   Accessed March 7, 2019. Published 2018.
  30. Kruse FM, Groenewoud S, Atsma F, van der Galiën OP, Adang EMM, Jeurissen PPT. Do independent treatment centers offer more value than general hospitals? the case of cataract care. Health Serv Res. 2019;54(6):1357-1365. doi:10.1111/1475-6773.13201
  31. Cook RD. Detection of influential observation in linear regression. Technometrics. 1977;19(1):15-18. doi:10.2307/1268249
  32. McDonald B. A teaching note on Cook’s distance-a guideline. Research Letters in the Information and Mathematical Sciences. 2002;3:127-128.
  33. Ferrari S, Cribari-Neto F. Beta regression for modelling rates and proportions. J Appl Stat. 2004;31(7):799-815. doi:10.1080/0266476042000214501
  34. Ospina R, Ferrari SLP. A general class of zero-or-one inflated beta regression models. Comput Stat Data Anal. 2012;56(6):1609-1623. doi:10.1016/j.csda.2011.10.005
  35. Chard J, Kuczawski M, Black N, van der Meulen J. Outcomes of elective surgery undertaken in independent sector treatment centres and NHS providers in England: audit of patient outcomes in surgery. BMJ. 2011;343:d6404. doi:10.1136/bmj.d6404
  36. Browne J, Jamieson L, Lewsey J, van der Meulen J, Copley L, Black N. Case-mix & patients’ reports of outcome in Independent Sector Treatment Centres: Comparison with NHS providers. BMC Health Serv Res. 2008;8:78. doi:10.1186/1472-6963-8-78
  37. Grisel J, Arjmand E. Comparing quality at an ambulatory surgery center and a hospital-based facility: preliminary findings. Otolaryngol Head Neck Surg. 2009;141(6):701-709. doi:10.1016/j.otohns.2009.09.002
  38. Chukmaitov AS, Menachemi N, Brown LS, Saunders C, Brooks RG. A comparative study of quality outcomes in freestanding ambulatory surgery centers and hospital-based outpatient departments: 1997-2004. Health Serv Res. 2008;43(5 Pt 1):1485-1504. doi:10.1111/j.1475-6773.2007.00809.x
  39. Hollingsworth JM, Saigal CS, Lai JC, Dunn RL, Strope SA, Hollenbeck BK. Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery. J Urol. 2012;188(4):1274-1278. doi:10.1016/j.juro.2012.06.031
  40. De Regge M, De Groote H, Trybou J, Gemmel P, Brugada P. Service quality and patient experiences of ambulatory care in a specialized clinic vs. a general hospital. Acta Clin Belg. 2017;72(2):77-84. doi:10.1080/17843286.2016.1216258
  41. Kelly MP, Calkins TE, Culvern C, Kogan M, Della Valle CJ. Inpatient versus outpatient hip and knee arthroplasty: which has higher patient satisfaction? J Arthroplasty. 2018;33(11):3402-3406. doi:10.1016/j.arth.2018.07.025
  42. Madison K. Multihospital system membership and patient treatments, expenditures, and outcomes. Health Serv Res. 2004;39(4 Pt 1):749-769.   doi:10.1111/j.1475-6773.2004.00256.x
  43. EY Healthcare. Barometer Nederlandse Gezondheidszorg. EY; 2017. https://www.ey.com/Publication/vwLUAssets/EY-barometer-nederlandse-gezondheidszorg-2017/$FILE/EY-barometer-nederlandse-gezondheidszorg-2017.pdf.  Accessed March 13, 2019.
  44. Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. Selective referral to high-volume hospitals: estimating potentially avoidable deaths. JAMA. 2000;283(9):1159-1166. doi:10.1001/jama.283.9.1159
  45. Pieper D, Mathes T, Neugebauer E, Eikermann M. State of evidence on the relationship between high-volume hospitals and outcomes in surgery: a systematic review of systematic reviews. J Am Coll Surg. 2013;216(5):1015-1025.e1018. doi:10.1016/j.jamcollsurg.2012.12.049
  46. Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94(2):145-161. doi:10.1002/bjs.5714
  47. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? a systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137(6):511-520. doi:10.7326/0003-4819-137-6-200209170-00012
  48. Hughes RG, Hunt SS, Luft HS. Effects of surgeon volume and hospital volume on quality of care in hospitals. Med Care. 1987;25(6):489-503. doi:10.1097/00005650-198706000-00004
  49. Kraus TW, Büchler MW, Herfarth C. Relationships between volume, efficiency, and quality in surgery--a delicate balance from managerial perspectives. World J Surg. 2005;29(10):1234-1240. doi:10.1007/s00268-005-7988-5
  50. Chukmaitov AS, Menachemi N, Brown SL, Saunders C, Tang A, Brooks R. Is there a relationship between physician and facility volumes of ambulatory procedures and patient outcomes? J Ambul Care Manage. 2008;31(4):354-369. doi:10.1097/01.JAC.0000336554.46837.a4
  51. Kruse FM, van Nieuw Amerongen MC, Borghans I, Groenewoud AS, Adang E, Jeurissen PPT. Is there a volume-quality relationship within the independent treatment centre sector? a longitudinal analysis. BMC Health Serv Res. 2019;19(1):853. doi:10.1186/s12913-019-4467-5
  52. Katz JN, Barrett J, Mahomed NN, Baron JA, Wright RJ, Losina E. Association between hospital and surgeon procedure volume and the outcomes of total knee replacement. J Bone Joint Surg Am. 2004;86(9):1909-1916. doi:10.2106/00004623-200409000-00008
  53. Marlow NE, Barraclough B, Collier NA, et al. Centralization and the relationship between volume and outcome in knee arthroplasty procedures. ANZ J Surg. 2010;80(4):234-241. doi:10.1111/j.1445-2197.2010.05243.x
  54. Chattha A, Muste J, Patel A. The impact of hospital volume on clinical and economic outcomes in ventral hernia repair: an analysis with national policy implications. Hernia. 2018;22(5):793-799. doi:10.1007/s10029-018-1803-3
  55. Chukmaitov A, Devers KJ, Harless DW, Menachemi N, Brooks RG. Strategy, structure, and patient quality outcomes in ambulatory surgery centers (1997-2004). Med Care Res Rev. 2011;68(2):202-225. doi:10.1177/1077558710378523
  56. Stadhouders NW, Kremer JAM, Jeurissen PPT, Tanke MAC. Do quality improvements in assisted reproduction technology increase patient numbers in a managed competition setting? Int J Health Plann Manage. 2019;34(2):e1312-e1322. doi:10.1002/hpm.2778
  57. Stolper KCF, Boonen LHHM, Schut FT, Varkevisser M. Managed competition in the Netherlands: Do insurers have incentives to steer on quality? Health Policy. 2019;123(3):293-299. doi:10.1016/j.healthpol.2018.08.018
  58. Ruwaard S, Douven R, Struijs J, Polder J. Hoe kopen zorgverzekeraars in bij ziekenhuizen: een analyse van de contracten tussen verzekeraars en ziekenhuizen. TPEdigitaal. 2014;8(2):98-117.
  59. Stolper KCF, Boonen LHHM, Schut FT, Varkevisser M. Managed competition in the Netherlands: do insurers have incentives to steer on quality? Health Policy. 2019;123(3):293-299. doi:10.1016/j.healthpol.2018.08.018
  60. Street A, Sivey P, Mason A, Miraldo M, Siciliani L. Are English treatment centres treating less complex patients? Health Policy. 2010;94(2):150-157. doi:10.1016/j.healthpol.2009.09.013
  61. Winter A. Comparing the mix of patients in various outpatient surgery settings. Health Aff (Millwood). 2003;22(6):68-75. doi:10.1377/hlthaff.22.6.68
  62. Meyerhoefer CD, Colby MS, McFetridge JT. Patient mix in outpatient surgery settings and implications for Medicare payment policy. Med Care Res Rev. 2012;69(1):62-82. doi:10.1177/1077558711409946
  63. Werner BC, Teran VA, Deal DN. Patient-related risk factors for infection following open carpal tunnel release: an analysis of over 450,000 Medicare patients. J Hand Surg Am. 2018;43(3):214-219. doi:10.1016/j.jhsa.2017.09.017
  64. Zorginstituut Nederland. Indicatorenset Carpaletunnelsyndroom. https://www.zorginzicht.nl/bibliotheek/Carpaletunnelsyndroom/RegisterMeetinstrumentenDocumenten/Indicatorgids%20CTS%202017.docx.   Accessed March 7, 2019. Published 2017.
  65. Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35(2):189-196. doi:10.1016/j.jhsa.2009.11.012
  66. Ponce BA, Cain EL Jr, Pflugner R, et al. Risk factors for revision anterior cruciate ligament reconstruction. J Knee Surg. 2016;29(4):329-336. doi:10.1055/s-0035-1554925
  67. Westermann R, Anthony CA, Duchman KR, et al. Infection following anterior cruciate ligament reconstruction: an analysis of 6,389 cases. J Knee Surg. 2017;30(6):535-543. doi:10.1055/s-0036-1593617
  68. Nakamura SJ, Conte-Hernandez A, Galloway MT. The efficacy of regional anesthesia for outpatient anterior cruciate ligament reconstruction. Arthroscopy. 1997;13(6):699-703. doi:10.1016/s0749-8063(97)90003-7
  69. Williams BA, Kentor ML, Vogt MT, et al. Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology. 2004;100(3):697-706. doi:10.1097/00000542-200403000-00034
  70. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177. doi:10.1097/01.SLA.0000081085.98792.3d
  71. Birrell F, Johnell O, Silman A. Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery. Ann Rheum Dis. 1999;58(9):569-572. doi:10.1136/ard.58.9.569
  72. Sinaiko AD, Rosenthal MB. Increased price transparency in health care--challenges and potential effects. N Engl J Med. 2011;364(10):891-894. doi:10.1056/NEJMp1100041