This was a note I prepared for myself
International experience
provides very little guidance to the problem of designing an effective health
system; there is little structural convergence between the health systems of
affluent countries on the supply-side.
One almost universal exception
to this pessimistic conclusion is that the funding of a health system needs to
be primarily unified and the role of private payments limited. This was a
conclusion of proponents of Obamacare. But entrenched interests left the US
with its fragmented healthcare funding which is generally thought to be one of
the reasons that the US has exceptionally poor health outcomes despite spending
more per capita than any other country and having some of the most advanced
medical centres in the world.
It is on the supply-side of
health delivery that there is so little agreement or convergence. The
divergences partly reflect differing sizes of nations and their constitutional
and fiscal arrangements. But there are also considerable differences in the
balance between public and private delivery of healthcare. In the case of a
unified funding system this amounts to some outsourcing, in which the central
agency funds the treatment which is provided by an agency which is not in the
public sector. (It may be for profit, not for profit, or charitable.)
There are various forms of
outsourcing. To make this paper tractable, it focuses only on secondary care.
Public-private partnerships are discussed in an appendix, which concludes that
it seems unlikely that PPPs, rigorously defined, have a significant role in New
Zealand’s public health system. The focus here is on the public sector
contracting out treatment to agencies outside the public hospital system.
This paper is presented with
large population centres using multiple possible private suppliers. Some
centres may not have that option. Centres in which there is only a single
feasible private supplier of a service raise the complication of bilateral monopolies,
which weakens the ability of the public hospital to get a good deal.
Contracting
Out
Contracting out is where the
public health system purchases (i.e. fully funds) a healthcare service which is
provided by a private agency. The possible services and reasons for the
transaction are numerous.
Contracting out non-medical
services, such as for cleaning and food services, is common. What seems to be
happening is that the medical management is contracting out a non-medical part
of the service to an agency with more expertise in the management of that
activity. The principle does not seem controversial although there may be
controversy about the particular quality of a contracted service.
Here are some examples of
medical contracting out which illustrate the variety and the broad reasons for
doing so.
– in about 1990, the (Labour) Government gave the
Tauranga Hospital a grant to reduce its surgical waiting-list backlog. The
hospital commissioned private providers to carry out the surgery, presumably
because the public hospital was already working at full capacity. (This was a
poster case for the supporters of the health redisorganisation of the time and
brought CEO Lester Levy to public prominence – not his fault. It actually
supported the dissenters. There were no efficiency gains, just extra funding.)
– about twenty years ago, a Wellington oncologist was
hired by Waikato Hospital to assess women with potential breast cancer who
would then be sent by the hospital to Sydney for treatment. Both the hiring of
the oncologist (he would have been on contract rather than salary) and the
Sydney treatment were contracting out caused by a shortage of local capacity.
– an Auckland dermatologist told me that the public
hospital did not have a particular piece of equipment but when it was needed
(for birthmarks, as I recall) they contracted out to a private provider who had
the equipment. There was not enough demand within the public service to fully
utilise the equipment, but the external provider was already using theirs to
meet private cosmetic demands.
– one Monday my public hospital doctors got my biopsy and
decided I needed a full-body CAT scan for the consultation on Wednesday. I got
the scan on the Tuesday from a private provider. I assume the public hospital
CATs were fully booked and that rather than bump someone else, my case was
outsourced. The backup MRI a few days later was booked and done in the public
hospital. (There was no
evidence of metastatic cancer.)
The above examples appear
primarily as a consequence of full utilisation of capacity in the public
sector. Here are some examples which might be more problematic.
– ACC tends to use the private sector, presumably to skip
public sector waiting lists. (This illustrates the dangers of multiple funders,
since accident victims need not be a higher medical priority than non-accident
patients.)
– Off-campus laboratory services are outsourced to a
(monopoly) private sector provider. I assume this is because the hospital
system does not want to run the myriad off-campus sites which are convenient
for those who need to be tested. Presumably the processes involved are
sufficiently routine not to require the tight-quality supervision that the
public hospital provides. (It has internal laboratory services for those in
treatment.)
– Ambulances are another example of specialist
outsourcing.
– I am told that the Wellington Hospital has insufficient
MRI scanners which means that some patients are referred to a private sector
provider. It could be argued that this example belongs to the earlier ones of
outsourcing because of lack of capacity but as usually explained, it seems that
the hospital has made a deliberate decision not to acquire another scanner. The
example needs to be teased out.
I am guessing that outsourcing
MRI investigations saves the hospital the capital outlay of installing another
scanner. There are parallels here with the public-private-partnership approach
set out in the appendix because it involves the private sector installing the
capital (e.g. equipment and accommodation). However it involves permanent
private ownership (typically, PPPs eventually revert to public ownership) and
there is no contractual obligation for the public hospital to use the private
scanner nor has the scanner an exclusive monopoly (another business could set
up in competition and the public hospital switch its custom or install its own
capacity). Thus it is not a PPP in terms of the NZ government accounting
conventions (neither is the outsourcing of cleaning or food services). Even so,
one is left a little uneasy if the reason for the outsourcing is to avoid
public sector capital investment. But that is also true for some of the
earliest group of outsourcing examples.
Evaluating
Outsourcing
There is such a variety of
ways of outsourcing it is difficult to evaluate them generally. Here follow
some pointers.
Does outsourcing reduce costs?
For a variety of reasons it may increase them. Capital costs are higher and it
is generally thought that salaries – at least of senior medical professionals –
are higher in the private sector than the public sector.
In one way, private provision
is likely to appear more expensive. A fully utilised service (as public
healthcare tends to be) has no downtime; the private healthcare service
covering it when the public supply is constrained must have periods in which
its equipment, and possibly labour, is not fully utilised. Thus the cost of
outsourcing is likely to be higher than internal provision except, of course,
the costs of providing above the public sector constraint will be higher than
average costs of its provision too.
There is a trope that the
public sector – in this context, the public delivery of healthcare – is always
inefficient. That can be true. There is (and should be) a constant effort to
reduce such inefficiencies as there are. But the issue here is whether the
private sector is any more efficient. We do not know but it is not obvious in
healthcare why it should be – ideology aside – when we do an exact case match.
It is an empirical question, which needs to be evaluated by case studies. There
are few such studies. (The
only one I know of — from the early 1980s, found the costs of public and
private cataract surgery were within a $1 of each other. The remunerations to
the private surgeons was higher, but it was offset by the private treatment
discharging the patient after one overnight stay, but the public treatment
keeping them for three nights. Nowadays it is day surgery.)
The point about the previous
paragraph is to be cautious about the claim that outsourcing to the private
sector reduces costs. That is an unproven hypothesis, not a fact.
(It should be acknowledged
that private provision may innovate new or more effective treatments – as will
the public sector. There is a general economic consensus that multiple
independent agencies tend to generate greater innovation.)
One issue which I have
wondered about is quality control. It seems to me that it is likely that public
provision has more checks and balances – in a large hospital anyway. When I
have discussed this with (even public sector) doctors they have discounted the
issue. I suspect that may be because the outsourced services are relatively
simple and quality control straight forward. (I have never heard of routine
multi-disciplinary meetings in the private sector.) Perhaps all that is needed
is that when outsourcing, a public hospital should require in the contract
quality standards similar to what it expects internally – and that their
expectations be enforced.
One concern is that
outsourcing may shift medical personnel from the public sector to the private
sector, both raising costs of provision and making equitable provision more
difficult because private treatment prioritises by ability to pay rather than
medical need. (The mechanism is that the public sector outsourcing provides a
base which enables the private practice.) Essentially, private payments
(including medical insurance) weaken unified funding.
A further issue is whether
practising in the private sector undermines commitments to the public sector.
It is sadly true that some doctors present themselves as if their chief loyalty
is to their remuneration – they may still be very good doctors. Generally
though, I’d have said that most doctors’ loyalty is to their profession. How
much equity of treatment (base on medical need) and hence the importance of
public provision may vary from doctor to doctor.
Conclusion
Disappointingly, this review
does not produce strong conclusions. The weak one is that outsourcing has a
role in public healthcare provision but it has to be carefully managed and not
used too extensively. The biggest danger identified here is that the public
hospital limits its capacity because of inadequate provision of capital, in
which case the outsourcing is nothing to do with healthcare but because the
government, in effect, borrows for the heathcare system without putting it on
the public balance sheet.
It looks like that in our
large centres, at least, are going to have an ecology of different suppliers
including private suppliers providing publicly funded services. What is
critical is that outsourcing does not undermine the commitment to a dominant unified
funder – the danger is that private insurance may reduce public pressure to
ensure there is adequate funding. Even more critical is the principle that
access to treatment be based on need rather than ability to pay.
Appendix:
Public Private Partnerships
Public private partnerships
(PPP) is a term which is used very loosely in the public discussion. It is a
form of outsourcing. Inconveniently the Government’s most recent policy
statement New
Zealand PPP Framework: A Blueprint for Future Transactions (to which
the Labour Opposition signed up) does not offer a definition.
An associated media
release describes how a PPP works as follows:
Normally,
a government agency would contract designers and architects to plan an
infrastructure project, builders and engineers to create the asset, and then
one or more contractors to maintain it for the rest of its life. The government
would take out a loan to pay for the build, and then pay this loan back over
time. It would be responsible for maintaining the asset as well.
With
a PPP, the government agency works out what it would cost them to build the
asset and maintain it for 25 years to a certain standard under the traditional
approach. Private sector bidders then work out how they can deliver these
bundled services to a better outcome for this same price. A PPP will only be
pursued and accepted if it delivers demonstrably better value than the agency
would have got by doing the job itself.
With
the bid accepted, the private sector partner then builds the asset and
maintains it for the next 25 years – billing the government quarterly
(including the repayment of debt incurred by the partner) from the time it’s
built until the 25 years is up. If the asset doesn’t meet the agreed
performance standards, the partner is paid less.
After
this, the debt has been repaid and the asset will have been maintained to a
pre-agreed condition. The government maintains ownership of the asset
throughout the 25-year period and beyond, taking responsibility for asset
management at the end of the PPP.
Thus a PPP is about the
financing and operation of a physical asset. It could apply to a hospital
building although there is no hint in the documents that this is a New Zealand
interest.
PPPs have been used in Britain
to develop hospitals. Generally the outcome has been very expensive. There are
particularities in Britain which made PPPs attractive (assuming they are cost
effective – they were not). The effect of British public accounting conventions
was that the PPPs were off-balance-sheet borrowings which allowed the British
government to claim to be below a set public borrowing limit while actually
exceeding it. New Zealand public accounting conventions are more rigorous so
this cannot happen here. For example, the liability to the government incurred
by the Transmission Gully motorway is explicitly reported in the public
accounts. One expert summarised the New Zealand convention that it includes ‘hire-purchase
as a debt’.
The recent government release
on PPPs states
PPP
procurement should not be categorised as a financing tool. While the PPP model
utilises private finance in support of achieving these enhanced outcomes,
spreading infrastructure related cash flows through project finance
arrangements is not the purpose of PPP procurement (if it were, this outcome
could be achieved more efficiently through general Crown borrowing to finance
infrastructure needs). (p.7)
It goes on:
One
of the features that has distinguished the New Zealand PPP approach from other
jurisdictions is the focus on greater outcomes rather than lower cost.
It is not obvious how a PPP
could generate ‘greater outcomes’ in the health sector which is dominated by
skilled professionals rather than capital. Hence, it seems is unlikely that
PPPs, rigorously defined, have a significant role in New Zealand’s public
health system. As discussed in the main text, the focus will be on contracting
out.