The Voice of Pro-Medicare Physicians in Canada
Evidence-informed, Values-driven
e-Rounds Issue 2, February, 2008
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A systematic review and meta-analysis of studies comparing mortality rates of private
for-profit and private not-for-profit hospitals P.J. Devereaux, et al CMAJ May 28, 2002;
166 (11) Available at Devereux et al.,CMAJ May 28, 2002
Background: The hypothesis that private for-profit health care results in increased
efficiency and quality of care is examined.
Objective: To compare the mortality rates in private for-profit versus private not-for-profit
hospitals in the United States.
Design: A meta-analysis consisting of fifteen observational studies involving more than
26000 hospitals and 38 million patients in the U.S.
Focus: Mortality rates of patients.
Results: There exists a significantly increased risk of mortality in private-for-profit
hospitals as compared to private not-for-profit hospitals in the US.
Limitations: The study design was a meta-analysis of previously conducted
observational and highly heterogeneous studies. As such, there could be other variables
that explain a reduced mortality rate in not-for-profit hospitals. However, careful
consideration of likely confounding variables, namely hospital teaching status, patient
disease severity, and proportion of publicly (eg, US Medicare) vs privately insured
patients, revealed that the conclusions may, if anything, underestimate the potential
increase in mortality associated with private for-profit hospital care.
Conclusion There is a significantly increased risk of mortality in private for-profit
hospitals as compared to private not-for-profit hospitals in the U.S.
Discussion: The increase in mortality in private for-profit institutions may be attributable
to the fact that investors expect a return on their investment, and the institutions indeed
have a fiduciary responsibility to their investors, first and foremost. As a consequence,
when dealing with patients for whom the reimbursement rate is similar (eg. Medicare fee
schedules), monies that would otherwise be spent on patient care must be siphoned off
as profit, reducing either quality of care (by employing fewer highly skilled personnel),
access to care (through refusing to treat the more severely ill and, therefore, more costly
patients) or both.
Relevance: While these are U.S. data, they address an issue being considered in
Canada, where we have little research and experience with private for-profit care. It can
be assumed that for-profit care providers in Canada would face the same problem as in
the U.S. in holding down costs while attempting to deliver quality care and to sustain a
profit. Therefore, not-for-profit hospitals in Canada are likely to offer better health
outcomes with respect to patient mortality, as they do in the U.S.
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