Is health reform coming to the UK? Since the middle of the decade, the NHS has used a tariff system which pays a fixed price per procedure. Now, however, the Financial Times, reports that the UK plans for “public and private hospitals to compete on price for the treatment of NHS patients.” The reform calls for quality monitoring to ensure that quality does not slip.
What do British health economists think of the reforms?
- Zack Cooper, a health economist at the London School of Economics, said introducing price competition “would be a hugely retrograde step”. In ordinary markets, he said, people can see the trade-off between price and quality. “But in healthcare, it is difficult to measure quality, partly because the process is complex and partly because it may take days, weeks or even years for the outcome of treatment to become evident.” [In the U.S.], the use of fixed prices in the federally funded Medicare programme for the elderly has helped raise quality. “I’m very pro-competition in healthcare,” he said. “But price competition is not the right way to do it.”
- Anita Charlesworth, chief economist at the Nuffield Trust health think-tank, said the evidence from the 1990s, when family doctors could negotiate on price, was that a huge amount of time and money went in to pricing rather than the appropriateness or quality of care
- Nick Bosanquet, professor of health economics at Imperial College, London, argues in favour of price competition. “If you want a more flexible system it is illogical to have fixed prices, and after years of fixed prices in the NHS there is still a big variation in the quality of care.”
In my opinion, the value of price competition depends on your perception of how well patients and government can judge quality. In a world without asymmetric information, it is clear that price competition is optimal. The government could buy medical services by optimizing along a continuum of quality and price. Even in the presence of asymmetric information, price competition can be a good thing especially if there are some observable–although imperfect–signals of quality.
If quality is completely unobservable, then providers would have an incentive to minimize quality and drive down price. Unless of course, patients take price as a signal for quality. In this case, higher priced providers could gain market share because of a false perception of quality.
In the case where the consumer would pay for medical services, one justification for fixed pricing would occur if the government is better able to measure quality than individuals. For instance, individuals may be better at judging quality in terms of office amenities and the physician’s bedside manner, but policymakers can better judge whether providers follow best practices and have superior outcomes on average. If society can agree that outcomes matter more than office amenities, than the government could regulate quality and counteract provider’s incentivize to drive down their costs to maximize profits.
It is not a foregone conclusion that the experts inside or outside the government can measure quality better than can patients. For instance, in the same FT article, Ms. Charlesworth, states that it “was ’particularly worrying’ that GPs will set local prices for mental health services where quality is even harder to measure than in acute care.” If quality is so difficult to measure, how can policymakers measure that quality has decreased after the implementation of price competition?