Simulating the impact of centralization of prostate cancer surgery services on travel burden and equity in the English National Health Service: A national population based model for health service re-design.

INTRODUCTION: There is limited evidence on the impact of centralization of cancer treatment services on patient travel burden and access to treatment. Using prostate cancer surgery as an example, this national study analysis aims to simulate the effect of different centralization scenarios on the number of center closures, patient travel times, and equity in access. METHODS: We used patient-level data on all men (n = 19,256) undergoing radical prostatectomy in the English National Health Service between January 1, 2010 and December 31, 2014, and considered three scenarios for centralization of prostate cancer surgery services A: procedure volume, B: availability of specialized services, and C: optimization of capacity. The probability of patients travelling to each of the remaining centers in the choice set was predicted using a conditional logit model, based on preferences revealed through actual hospital selections. Multivariable linear regression analysed the impact on travel time according to patient characteristics. RESULTS: Scenarios A, B, and C resulted in the closure of 28, 24, and 37 of the 65 radical prostatectomy centers, respectively, affecting 3993 (21%), 5763 (30%), and 7896 (41%) of the men in the study. Despite similar numbers of center closures the expected average increase on travel time was very different for scenario B (+15 minutes) and A (+28 minutes). A distance minimization approach, assigning patients to their next nearest center, with patient preferences not considered, estimated a lower impact on travel burden in all scenarios. The additional travel burden on older, sicker, less affluent patients was evident, but where significant, the absolute difference was very small. CONCLUSION: The study provides an innovative simulation approach using national patient-level datasets, patient preferences based on actual hospital selections, and personal characteristics to inform health service planning. With this approach, we demonstrated for prostate cancer surgery that three different centralization scenarios would lead to similar number of center closures but to different increases in patient travel time, whilst all having a minimal impact on equity

Competition among social health insurers: A case study for the Netherlands, Belgium and Germany

The idea that competition generally enhances efficiency is hardly under discussion anymore. The market for health insurance is, however, no ordinary market as asymmetrical information can lead to adverse selection and cream skimming. Adequate risk-adjustment removes the incentives for cream skimming and balances the negative consequences of adverse selection. In an attempt to enhance efficiency, the Dutch government in 1992 introduced price competition between social health insurers in combination with risk-adjusted capitation payments. Our estimation results indicate that this has not resulted in altering market shares. Also in Belgium and Germany social health insurers are faced with incentives to operate more efficiently. These countries encounter similar difficulties. Because equity considerations are high valued features of the Dutch health insurance system, competition is difficult to implement. We recommend that the current capitation formula should be refined and that the insurers should be given more room for selective contracting of health care providers

Why do patients bypass the nearest hospital? An empirical analysis for orthopaedic care and neurosurgery in the Netherlands

Patient choice behaviour, Hospital bypassing, Hospital competition, I11, C25, D12,