Physicians in private practice: reasons for being a social franchise member

Huntington Dale, Mundy Gary, Hom Nang, Li Qingfeng, Aung, Aung Tin

Description

Evidence is emerging on the cost-effectiveness, quality and health coverage of social franchises. But little is known about the motivations of providers to join or remain within a social franchise network, or the impact that franchise membership has on client volumes or revenue earnings. Methods (i) Uncontrolled facility based of a random sample of 230 franchise members to assess self-reported motivations; (ii) A 24 month prospective cohort study of 3 cohorts of physicians who had been in the franchise for 4 years, 2 years and new members to track monthly case load and revenue generated. Results The most common reasons for joining the franchise were access to high quality and cheap drugs (96.1%) and feelings of social responsibility, (95.2%). The effects of joining the franchise on the volume of family planning services is shown in the 2009 cohort where the average monthly service volume increased from 18.5 per physician to 70.6 per physician during their first 2 years in the franchise, (p<0.01). These gains are sustained during the 3 rd and 4 th year of franchise membership, as the 2007 cohort reported increases of monthly average family planning service volume from 71.2 per physician to 102.8 per physician (p<0.01). The net income of cohort 2009 increased significantly (p=0.024) during their first two years in the franchise. The results for cohorts 2007 and 2005 also show a generalized trend in increasing income. Conclusions The findings show how franchise membership impacts the volume of franchise and non-franchised services. The increases in client volumes translated directly into increases in earnings among the franchise members, an unanticipated effect for providers who joined in order to better serve the poor. This finding has implications for the social franchise business model that relies upon subsidized medical products to reduce financial barriers for the poor. The increases in out of pocket payments for health care services that were not price controlled by the franchise is a concern. As the field of social franchises continues to mature its business models towards more sustainable and cost recovery management practices, attention should be given towards avoiding commercialization of services.

Sujets

• Social franchising
• Reproductive health
• Myanmar

Informations

• Publié par: biomed
• Publié le: 01 janvier 2012
• Nombre de lectures: 15
• Langue: English

Extrait

Huntington
etal.HealthResearchPolicyandSystems
2012,
10
:25
http://www.health-policy-systems.com/content/10/1/25

RESEARCH

OpenAccess

Physiciansinprivatepractice:reasonsforbeinga
socialfranchisemember
DaleHuntington
1*
,GaryMundy
2
,NangMoHom
3
,QingfengLi
4
andTinAung
3

Abstract
Background:
Evidenceisemergingonthecost-effectiveness,qualityandhealthcoverageofsocialfranchises.But
littleisknownaboutthemotivationsofproviderstojoinorremainwithinasocialfranchisenetwork,ortheimpact
thatfranchisemembershiphasonclientvolumesorrevenueearnings.
Methods:
(i)Uncontrolledfacilitybasedofarandomsampleof230franchisememberstoassessself-reported
motivations;(ii)A24monthprospectivecohortstudyof3cohortsofphysicianswhohadbeeninthefranchisefor
4years,2yearsandnewmemberstotrackmonthlycaseloadandrevenuegenerated.
Results:
Themostcommonreasonsforjoiningthefranchisewereaccesstohighqualityandcheapdrugs(96.1%)
andfeelingsofsocialresponsibility,(95.2%).Theeffectsofjoiningthefranchiseonthevolumeoffamilyplanning
servicesisshowninthe2009cohortwheretheaveragemonthlyservicevolumeincreasedfrom18.5perphysician
to70.6perphysicianduringtheirfirst2yearsinthefranchise,(p<0.01).Thesegainsaresustainedduringthe3
rd
and4
th
yearoffranchisemembership,asthe2007cohortreportedincreasesofmonthlyaveragefamilyplanning
servicevolumefrom71.2perphysicianto102.8perphysician(p<0.01).Thenetincomeofcohort2009increased
significantly(p=0.024)duringtheirfirsttwoyearsinthefranchise.Theresultsforcohorts2007and2005alsoshow
ageneralizedtrendinincreasingincome.
Conclusions:
Thefindingsshowhowfranchisemembershipimpactsthevolumeoffranchiseandnon-franchised
services.Theincreasesinclientvolumestranslateddirectlyintoincreasesinearningsamongthefranchise
members,anunanticipatedeffectforproviderswhojoinedinordertobetterservethepoor.Thisfindinghas
implicationsforthesocialfranchisebusinessmodelthatreliesuponsubsidizedmedicalproductstoreducefinancial
barriersforthepoor.Theincreasesinoutofpocketpaymentsforhealthcareservicesthatwerenotprice
controlledbythefranchiseisaconcern.Asthefieldofsocialfranchisescontinuestomatureitsbusinessmodels
towardsmoresustainableandcostrecoverymanagementpractices,attentionshouldbegiventowardsavoiding
commercializationofservices.
Keywords:
Socialfranchising,Reproductivehealth,Myanmar

Introduction
Therehasbeensomevariationinthetypesofproviders
Duringthepastdecadesocialfranchiseshavemovedwhoaremembersofasocialfranchise,butingeneral
fromanemergent,proofofconceptstageofdevelop-thefollowingcharacteristicsdefineasocialfranchise:
menttobeingestablishednetworksofprivatesectorclinicsareoperatorowned,paymentstotheproviderare
providersforreproductivehealthandotherprimarycarefeeforservice(andaremadebythepatient,athird
services.Atthecloseof2011therewere59franchisedparty,voucherorothersystem),servicesarequalitycon-
networksofover150,000privatepracticeproviderstrolled/standardizedandincludebothfranchiseand
spreadover35lowandmiddleincomecountries,serv-non-franchisesupportedservices,[2,3].
inganestimated31millionpoorpatientsannually[1].Thegoalsofasocialfranchisenetworkhaveremained
remarkablyconsistentoverthisperiodofgrowth:(i)Ac-
*
1
Correspondence:[e-mail]
cess:increasecoveragethenumberofprovidersand
ReproductiveHealthandResearchDepartment,WorldHealthOrganization,
healthcareservicesoffered;(ii)Cost-effectiveness:
Geneva,Switzerland
Fulllistofauthorinformationisavailableattheendofthearticle
©2012Huntingtonetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,
distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Huntington
etal.HealthResearchPolicyandSystems
2012,
10
:25
http://www.health-policy-systems.com/content/10/1/25

provideaserviceatanequalorlowercosttootherser-
vicedeliveryoptionsinclusiveofsubsidyorsystemcosts;
(iii)Quality:provideservicesthatadheretoqualitystan-
dardsandimprovethepre-existinglevelofquality;and
(iv)Equity:serveallpopulationgroups,emphasizing
thoseinneed,[3,4].Thebasicbusinessmodelforthe
franchiserhasalsoremainedlargelyunchangedaswell:
thefranchiserisdependentuponexternalfundingto
supportthecostsofnetworkmanagement,commodity
subsidies,qualityassurance.Somefranchiseshavebeen
movingtowardsmorecommercialmodelsofoperating
thenetworks(e.g.,chargingmembershipfees),butnone
operateonacostrecoverybasis.
Thespeedatwhichtheprivatesectoringeneraland
socialfranchisesinparticularhaveexpandedoperations
hasoutpacedtheavailabilityofevidenceontheircost-
effectiveness,changesinservicequality,impacton
healthcoverage,outcomesandequity,[5,6]Someevi-
denceisemergingthatindicatessocialfranchisedhealth
serviceshavehadapositiveimpactonthenumberofre-
peatusersoffamilyplanning,[7,8],servicequalityas
perceivedbyclients[9],andthefranchise'sabilityto
servepoorandvulnerablepopulations[10].Butthere
hasbeeninsufficientattentioninthepublishedliterature
oneitherthemotivationsofproviderstojoinorremain
withinasocialfranchisenetwork,ortoevaluatetheim-
pactthatfranchisemembershiphasonclientvolumesor
revenueearnings,[11].Withpricecapitationsoftenset
belowtheproviders
’
customaryfeesandtheincreased
administrativeburdensoffranchisedmembership,the
motivationsofproviderstojoinandremainwithinaso-
cialfranchisearepoorlyunderstood.Thisinformationis
criticallyimportantgivenrecentevidenceonrelative
highcostsassociatedwithmanagingafranchise[12].
However,thereisingeneralverylittleevidenceinthe
publishedliteratureonthesustainabilityofsocialfran-
chisemodels,[13].
ThisstudyofprovidersintheSunQualityHealthnet-
workinMyanmaraddressesthisgapintheevidence
baseonsocialfranchisesthroughitsexplorationofpro-
vidermotivations
–
bothfinancialandnon-monetary
–
forjoiningandremaininginasocialfranchise.
Settingofthestudy
PopulationServicesInternational/Myanmarestablished
theSunQualityHealth(SQH)franchisein2001andby
theendof2011thenumberofactivemembersinthe
networkreached1,462.Inlate2008therewere748
physician-membersofSQHwhoprovidedReproduct-
iveHealth(RH)services(outofatotalof797SQHac-
tivemembers)spreadover140townshipsin12states.
Physiciansarecarefullyselectedtojointhefranchise
throughasubjectiveassessmentconductedbySQH
management,basedontheprovider'sreputation,length

Page2of8

ofservice,interesttoservicesavailableinthenetwork,
theaccessibilityoftheclinictopoorandthecliniccon-
ditions.Assuch,SQHmembersmaybesomewhatdif-
ferentthanthegeneralpopulationofprivatepractice
physiciansinMyanmar.ProviderswhojointheSQH
franchisearefeeforservice,licensedGeneralPracti-
tionerslocatedinperi-urbanareasofcitiesandsmall
townswheremultipleothersourcesofcareareavailable,
includinggovernmentclinics.Theyworkfull-timein
theirclinics,manykeepingtheirclinicopenuntil7or
8pm.Physiciansareenrolledthroughaone-weeklong
inductiontraining,inbatchesofapproximately20.An-
nuallyaround100newmembershavebeenaddedtothe
franchisenetworksinceitslaunch
MembersoftheSQHfranchiseprovidebothfran-
chisedsupported(familyplanning,TB,pneumonia,mal-
ariaandHIVtesting)andnon-franchisedservices.For
thefranchisesupportedservices,theprovideragreestoa
pricecapitationonthemedicalproduct(whichishighly
subsidized)andconsultationfees.However,fornon-
franchisesupportedservicestherearenocapitations.
Franchisemembersalsoprovidemonthlyreportsonthe
volumeofconsultationsandcommoditiessoldforthe
franchisesupportedservicesandalsoagreetoadhereto
servicequalitystandardsincludingperiodicqualitycon-
trolvisits.Inreturnthefranchisemembersbenefitby
signage(thatindicatesqualitystandardstopatients),
receivedmedicalproductathighlysubsidizedprice,in-
servicetrainingandup-todateinformation.
Studydesign
Theresultsfromtwoseparatestudyelementsare
reportedonhere.Oneelementusedanuncontrolledob-
servationaldesign:230SunQualityHealthclinicswere
randomlyselectedwithprobabilityproportionatetosize
basedonaveragefamilyplanningcaseload(SQHstatis-
ticaldatasource).Fromthissampleoffacilities,228
memberphysiciansagreedtobeinterviewedfrom100
townshipsin10statesanddivisionsspreadacross
country.
Thesecondelementutilizedaprospectivecohort
studydesigntoexaminechangesintheproviders'case
loadvolumeandincomeoveratwoyearperiod.Based
onanecdotalexpertopinionfromtheSQHfranchise
management,thefulleffectsofjoiningthefranchise
wereestimatedtobecomeapparentonlyafteraperiod
oftimehadelapsedaftertheproviderjoinedthefran-
chise(inordertoallowforthecommunityservedto
recognizethebenefits).Thereforea2yearstudyperiod
wasusedinthecohortstudytoallowforthemoresus-
tainedeffectstobeevident,andtoassessifdifferent
cohortsoffranchisemembersareexperiencingsimilar
trajectoriesofrevenueandcaseloadgrowth.We
selected3cohortsofproviderstoexplorethissupposed

Huntington
etal.HealthResearchPolicyandSystems
2012,
10
:25
http://www.health-policy-systems.com/content/10/1/25

2yeareffect:providerswhojoinedthefranchisein2005,
2007and2009(i.e.,thosewhohadbeeninthefranchise
4years,2yearsorwerenewmembersatthetimeofour
study).
Samplecharacteristi