Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis

Abstract

S eparating issues of funding (i.e., who pays for health care) and delivery (i.e., who owns and administers the institutions providing care) helps to inform debates about health care systems. Funding for health care can come through private sources, primarily administered through insurance companies, or through public payment, by governments using tax dollars. Care can be delivered at private for-profit institutions that are owned by investors; private not-for-profit institutions that are owned by communities, religious organizations or philanthropic groups; or public health care institutions owned and administered by the government.Canadian hospitals are publicly funded. In terms of delivery, although they are commonly referred to as public institutions, Canadian hospitals are almost all owned and operated by private not-for-profit organizations.1 Canadian policy-makers continue to consider an expansion of private for-profit health care delivery, including private for-profit hospitals. 1 We have previously demonstrated higher risk-adjusted death rates among patients receiving care at private forprofit hospitals than among patients at private not-forprofit hospitals in a comprehensive systematic review. 2Uncertainty remains, however, about the economic implications of these forms of health care delivery. Studies evaluating the economics of health care delivery usually evaluate costs, charges or payments for care.3 From the perspective of a service provider, costs represent how much the provider paid to provide care, charges represent how much the provider billed the payer, and payments represent how much the provider received for the care received. In the context of publicly funded health care, the central policy question is how much government will pay for care delivered by private for-profit versus private notfor-profit providers. We therefore undertook a systematic for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals. Uncertainty remains, however, about the economic implications of these forms of health care delivery. Since some policy-makers might still consider for-profit health care if expenditure savings were sufficiently large, we undertook a systematic review and meta-analysis to compare payments for care at private forprofit and private not-for-profit hospitals. Methods: We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-forprofit hospitals. We masked the study results before teams of 2 reviewers independently evaluated the eligibility of all studies. We confirmed data or obtained additional data from all but 1 author. For each study, we calculated the payments for care at private for-profit hospitals relative to private notfor-profit hospitals and pooled the results using a random effects model. Results: Eight observational studies, involving more than 350 000 patients altogether and a median of 324 hospitals each, fu...

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