What are the implications of allowing for-profit delivery of health care? Although I admire the courage of P.J. Devereaux and coauthors1 in attempting a meta-analysis of this literature, as they noted there is enormous variability within each category. Not all hospitals are alike. In addition to the distinction the authors accurately make between private for-profit and private not-for-profit hospitals, the literature also suggests there are major differences between for-profit firms that are investor owned and those that operate as small businesses. Differences may also exist between organizations because of varying degrees of control by health professionals. Further compounding the difficulty in making comparisons, the for-profit hospitals included in the studies that Devereaux and coauthors reviewed tended to occupy niche markets, serving different target populations (and often performing different mixes of services) than did the not-for-profit organizations. Comparisons therefore often depend on what and how various factors are controlled for, making precise point estimates even more tenuous.
Regardless of the implications for costs (which are subject to similar apples-to-oranges difficulties), quality differences between for-profit and not-for-profit organizations appear to be less pronounced when clinicians are able to influence the care they give without direct pressure to balance their clinical judgement against shareholder returns.
Raisa B. Deber Professor Department of Health Policy, Management and Evaluation University of Toronto Toronto, Ont.
Reference
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