Poster #163 - Public vs Private Chronic Care: HIV Care Utilization, Cost, and Quality in a Single-payer System

• In Event: Saturday Poster Luncheon

Abstract

While public and private financing of healthcare have been studied extensively, public vs private provision has received less attention. The cost of chronic care, such as HIV care, can accumulate to a sizable burden on both patients and healthcare systems. The differences in public vs private provision can be extensive given the differences in the objectives of public not-for-profit and private for-profit facilities. We developed a theoretical model which explains the differences in public vs private provision of care and we employed an instrumental variable method to estimate the size of those differences in terms of utilization, expenditure, and quality of HIV care.

The Military Health System (MHS) is a large single-payer system comprised of both public military and private civilian facilities which presents a unique opportunity to study public vs private provision of care within a single system. Healthcare records for 2,837 military dependent and retiree beneficiaries with HIV of age 18-64 for 2008-2018 were extracted from the MHS Data Repository. Beneficiaries with other health insurance coverage were excluded. The outcomes included annual primary and specialty care utilization, expenditure, and quality. The quality-of-care measures were based on the Ryan White Care Act performance measures and included regular HIV visits, antiretroviral therapy receipt, and absence of AIDS-defining conditions. We employed an instrumental variable method to address the endogeneity arising due to high/low utilization and cost patients selecting into public vs private care. We instrumented the receipt of public military vs private civilian care with an administrative rule that assigns a patient to a public military or private civilian primary care manager based on the patient’s distance to the closest public military facility.

A naïve comparison revealed that private care patients had higher primary care utilization (9.89 vs 1.88 procedures per year) and expenditure ($540 vs $348 per year) as well as higher specialty care utilization (45.74 vs 19.55 procedures per year) and expenditure ($18,531 vs $6,609 per year) but lower likelihood of regular HIV visits (45% vs 54% in a given year). The instrumental variable analysis, however, failed to detect statistically significant differences in primary and specialty care utilization, expenditure, or quality of HIV care. The compliers to whom the instrumental variable results generalize are 31–59-year-olds in the Southern and Western regions of the US.

While a naïve comparison would suggest that private facilities provide more care at a higher cost and lower quality, we find little evidence that assigning a patient to private vs public care affects outpatient utilization, cost, or quality. This is surprising given that while the objectives of both public and private facilities may consist of patient wellbeing, the objective of private for-profit facilities also consists of profits. Following our theoretical model, we attribute the naïvely observed differences in utilization, expenditure, and quality to differences in unobserved patient preferences for healthcare and self-selection into public and private care. We emphasize the importance of accounting for this type of endogeneity when providing credible information to policymakers.

Author

• Senay Dzhelal Topal, Uniformed Services University of the Health Sciences
  Presenting Author