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

From the Department of Medicine (Devereaux, Cook, Guyatt), the Department of Clinical Epidemiology and Biostatistics (Devereaux, Heels-Ansdell, Lacchetti, Haines, Cook, Walter, Bhandari, Lavis, Stoddart, Guyatt), the Faculty of Medicine (Stone), the Department of Surgery (Bhandari), the Department of Political Science (Lavis) and the Centre for Health Economics and Policy Analysis (Stoddart), McMaster University, Hamilton, Ont; the Faculty of Medicine (Ravindran), Inner City Health Research Unit, St. Michael's Hospital, and the Department of Medicine (Bayoumi), Cancer Care Ontario and the Department of Health Policy Management and Evaluation, University of Toronto (Sullivan), and AXON Clinical Research (McDonald), Toronto, Ont.; the Department of Medicine, University of Western Ontario, London, Ont. (Burns); the Department of Medicine, University of Ottawa, Ottawa, Ont. (Patel); the Departments of Medicine and Social and Preventive Medicine, University at Buffalo, Buffalo, NY (Schünemann); the Vancouver Coastal Health Research Institute and the Department of Anesthesia, University of British Columbia, Vancouver, BC (Choi)

Abstract

Background: It has been shown that patients cared for at private 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 for-profit 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Methods: We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-for-profit hospitals.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 not-for-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, fulfilled our eligibility criteria. In 5 of 6 studies showing higher payments for care at private for-profit hospitals, the difference was statistically significant; in 1 of 2 studies showing higher payments for care at private not-for-profit hospitals, the difference was statistically significant. The pooled estimate demonstrated that private for-profit hospitals were associated with higher payments for care (relative payments for care 1.19, 95% confidence interval 1.07–1.33, p = 0.001).

Interpretation: Private for-profit hospitals result in higher payments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.

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