PrivateHospitalsinTaiwan&TheImplica6ons

FredYangVisi-ngFellow,APARCCEO,MissionCare,Taiwan

APRIL19,2016

HospitalsinEast-AsianCountries

•  InJapan,mosthospitalsareprivatelyownedbyphysicians

•  InSouthKorea,96%ofhospitalsareprivate,morethan50%arefor-profit.

•  InTaiwan,70%ofhospitalsandbedsareprivate.

•  InChina,45%ofhospitalsareprivate,buttheyonlyaccountfor10%oftotalbeds

2Source:Compara-veHealthPolicyinTheAsiaPasific

HospitalsbyOwnership

•  Public(PUB)•  Privatenon-profit(PNP)•  Privatefor-profit(PFP)

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HospitalOwnership&Quality

LiteratureReview

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Summary:Doesownershipmaaer?

IntermsofQualityofCare&Pa-entOutcomes….•  Privatebeaerthanpublic•  Non-profitbeaerthanfor-profit

…butdifferencesnotreallybig.

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ResearchFocus

•  Taiwan’srecentexperiences•  Na-onalHealthInsuranceDataset,2010-2015Q2

•  Comparingquality&outcomesindicatorsbyhospitalownership

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DataSetCharacteris-cs

•  Validity –  computed & published by National Health Insurance

Administration (NHIA), not self-reported by individual hospitals

–  widely used in academic researches

•  Representativeness –  Indicators selected by a committee composed of government

officers, academic scholars and hospital representatives

•  Timeliness –  Hospital reimbursement claim data reported monthly

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HospitalsinTaiwan

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Localhospital 427 417 414 397 383 385 378 374 373 370 367 368Regionalhospital 80 73 70 72 77 78 81 83 83 82 83 83Medicalcenter 24 21 24 23 23 23 23 22 22 22 26 26

0

100

200

300

400

500

600

Num

bero

fhospitals

12Source:DepartmentofHealth,Taiwan

HospitalLevelsinTaiwan

•  MedicalCenter–  800+beds–  Teaching&researchamust– MostlypublicandPNP

•  RegionalHospital– Mostly300-800beds–  AgoodmixofPUB,PNP,PFP

•  LocalHospital–  <300beds,mostly<100beds– Mostlyprivate

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RegionalHospitalsbyOwnershipTypeOwnership Category Number %

Private PFP 15 18%

Religiousfacili6esNon-profitOrganiza6on(NPO)Privatemedicalschoolaffiliates

PNP 34 41%

GovernmentalVeterans,MilitaryHospitalsPublicmedicalschoolaffiliates

PUB 34 41%

Total 83 100%

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NHIAHomepage

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PublicInforma-onofQuality

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QualityInfobyindividualhospital

Defini-onsofqualityindicators

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HospitalQualityIndicatorsMedica-onsafety

No. Qualityindicators Datadura6on

1

Therapeu-cduplica-ons

rates

Samehospital

An--hypertensive(oral)

2011Q1-2015Q2

2 An--hyperlipidemia(oral)

3 An--diabe-c

4 an--psychosisdisorder

5 an--depression

6 seda-vehypno-cs

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Crosshospital

An--hypertensive(oral)

8 An--hyperlipidemia(oral)

9 An--diabe-c

10 an--psychosisdisorder

11 an--depression

12 seda-vehypno-cs

13 >10drugsprescribedperprescrip-on 2012Q1-2015Q2

14 An-bio-csadministered>3daysforcleanwoundsurgery 2009Q1-2015Q2

15 ChronicDiseaseRefillPrescrip-onRate 2009Q1-2015Q2

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HospitalQualityIndicatorsPa-entOutcomes

No. Qualityindicators Datadura6on

16 Crea-ninetes-nginDMpa-ents 2010Q1-2015Q1

17 Hypertensionpa-entwithhyperkalemiahistoryprescribedPotassium-sparingdiure-csorAldosteroneantagonist 2010Q1-2015Q2

18 Hypertensionpa-entwithhyperkalemiahistoryprescribedPotassium-sparingdiure-csorAldosteroneantagonistandfollowingPotassium(K) 2012Q1-2015Q2

19 Samedayrevisitofpa-entswithsamediagnosis 2011Q1-2015Q2

20 LOS>30daysofacuteinpa-entsRate 2010Q1-2015Q2

21 <14daysunplannedReadmissionRate 2012Q1-2015Q2

22 <14daysunplannedReadmissionpostdischargeofchildbirth 2008Q1-2015Q2

23 ERvisitswithin3daysalerdischarge 2010Q1-2015Q2

24 ERvisitsorhospitaliza-on<2dayspostoutpa-entsurgery(includingESWL) 2009Q1-2015Q2

25 ERpa-entstobeadmiaedwai-ng-me>48hours 2010Q1-2015Q1

26 SamedayERrevisit 2010Q1-2015Q2

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StudyMethods•  Descrip-veanalysis

– Meansandmedianofeachqualityindicatorbyownership

•  Differenceofeachqualityindicatorbyownership– Univariateanalysis

•  Kruskal-Wallistest•  Dunn‘smul-plecomparison

– Mul-variableanalysis•  Generalizedlinearmodelbyadjus-ngforcasemixindex

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Results

Descrip-veanalysis,meanbyownershipMedica-onsafety

No. Qualityindicators PFP PNP PUB

1

Therapeu-cduplica-ons

rates

Samehospital

An--hypertensive(oral) 0.24% 0.25% 0.26% 2 An--hyperlipidemia(oral) 0.20% 0.18% 0.19% 3 An--diabe-c 0.20% 0.19% 0.21% 4 an--psychosisdisorder 1.07% 1.11% 1.12% 5 an--depression 0.25% 0.28% 0.31% 6 seda-vehypno-cs 0.40% 0.42% 0.47% 7

Crosshospital

An--hypertensive(oral) 0.84% 0.83% 0.98% 8 An--hyperlipidemia(oral) 0.51% 0.45% 0.51% 9 An--diabe-c 0.65% 0.57% 0.72%

10 an--psychosisdisorder 1.11% 1.13% 1.15%

11 an--depression 1.02% 0.93% 1.08%

12 seda-vehypno-cs 3.96% 3.07% 3.33%

13 >10drugsprescribedperprescrip-on 0.87% 1.15% 0.74%

14 An-bio-csadministered>3daysforcleanwoundsurgery 18.74% 17.23% 19.60%

15 ChronicDiseaseRefillPxRate 25.09% 27.07% 21.86%

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Descrip-veanalysis,meanbyownershipOutcomeindicators

No. Qualityindicators PFP PNP PUB

16 Crea-ninetes-nginDMpa-ents 79.01% 75.11% 76.79%

17 Hypertensionpa-entwithhyperkalemiahistoryprescribedPotassium-sparingdiure-csorAldosteroneantagonist 4.11% 3.98% 4.25%

18 Hypertensionpa-entwithhyperkalemiahistoryprescribedPotassium-sparingdiure-csorAldosteroneantagonistandfollowingPotassium(K)

63.84% 75.13% 66.75%

19 Samedayrevisitofpa-entswithsamediagnosis 0.99% 1.11% 0.72%

20 LOS>30daysRateofacuteinpa-ents 0.95% 1.14% 1.74%

21 <14daysunplannedReadmissionRate 6.41% 7.48% 7.84%

22 <14daysunplannedReadmissionpostdischargeofchildbirth 0.49% 0.48% 0.62%

23 ERvisitswithin3daysalerdischarge 1.83% 2.38% 2.01%

24 ERvisitsorhospitaliza-on<2dayspostoutpa-entsurgery(includingESWL) 1.88% 1.65% 1.65%

25 ERpa-entstobeadmiaedwai-ng-me>48hours 0.60% 1.51% 1.12%

26 SamedayERrevisit 0.43% 0.40% 0.41%

27 Casemixindex 1.05 1.13 1.12 23

Mul-variableanalysis No Qualityindicators Ownershipcomparison

5 Same hospital therapeutic duplications rates for anti-depression PUB>PFP

7 Cross hospital therapeutic duplications rates for anti-hypertensive (oral) PUB>PFP

12 Cross hospital therapeutic duplications rates for sedative hypnotics PFP>PNP=PUB

13 > 10 drugs prescribed per prescription PNP>PUB

15 Chronic Disease Refill Prescription Rate PNP>PUB

18 Hypertension patient with hyperkalemia history prescribed Potassium-sparing diuretics or Aldosterone antagonist and following Potassium (K) PNP>PUB

20 LOS > 30 days of acute inpatients Rate PUB>PFP

21 < 14 days unplanned Readmission Rate PUB>PFP

Sta-s-calmethod:Generalizedlinearmodeladjus-ngforcasemixindexThelistedresultswerethosewithpvalue<0.05inmul-variableanalyses

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Summary

•  NosignificantdifferencesbetweenPNPsandPFPsinmostindicators

•  Privatehospitalsslightlybeaerthanpublichospitalsinoverallperformance

•  Consistentwithfindingsofmoststudiesinliterature

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Limita-ons

•  Regional(midsize)hospitalsonly(250-1200beds)

•  NHIdataonly,noinforma-onofout-of-pocketservices,whichaccountforabout20%oftotalhealthexpenditure

•  Interna-onalcomparisons

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Appendix

Taiwan’sHealthcareQuality

Efforts&System

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QualityImprovementEfforts

•  Externalaudit– TaiwanHospitalAccredita-on(1978)–  JointCommissionofTaiwan(1999)–  JointCommissionInterna-onal(2006)– Na-onalQualityAward(voluntary)

•  TaiwanCDCqualitycampaigns– Handhygiene– Bundlecare(UTI、VAP、CVP)– EnhanceAn-microbialStewardship

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QualityMonitoringSystem

•  TaiwanQualityIndicatorsProgram(TQIP)•  TaiwanHealthIndicatorsSystem(THIS)•  TaiwanClinicalPerformanceIndicators(TCPI)•  NHIAOpenInforma-onofQuality

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Implica-ons

•  IsPNPtherightsolu-onforChina’shealthcarereform?

Probablynot.•  What’swrongwithChina’sPUB&PFP?•  Effec-veexternalaudi-ngsystems•  Informa-ontransparency•  Qualitycompe--on

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Thankyou!

Q&A

Acknowledgements

•  Prof.Chih-ChengHsu,Na-onalHealthResearchIns-tute,Taiwan

•  Ming-ChinLiu,Analyst,CenterofQualityAssurance,MissionCare,Taiwan

•  Prof.KarenEggleston,ShorensteinAPARC,StanfordUniversity

•  HelenLie,Ed.D.,OralCommunica-onProgram,StanfordUniversity

•  QualityTeam,MissionCare,Taiwan

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