Ageing is a common risk factor for numerous chronic diseases, such as cancers, diabetes, and cardiovascular diseases [1]. A systematic review reveals that more than half of older adults aged 65 and older are living with multimorbidity, the co-occurrence of two or more chronic diseases [2]. Multimorbidity is associated with a range of adverse outcomes, including frailty and disability, and eventually substantial higher health care utilization and costs [3–6]. In other words, population ageing poses a great challenge to medical service provision and resources [7]. This gives rise to the importance of primary care, the gatekeeper of the whole healthcare system. Family doctor is the major primary care service provider who offers comprehensive, person-centered, continuous, preventive and coordinated care [8]. Indeed, evidence has demonstrated that health systems which rely more on primary care can result in better health outcomes and lower healthcare costs [9, 10]. However, most health systems adopt specialist care or single-disease approaches in the care of patients [11]. As such, we should strengthen primary care to provide coordinated and personalized care to patients with complex healthcare needs [9, 12, 13].
Hong Kong has a two-tier healthcare system in which the service provision is different between the public and the private sector. The public sector provides around 90% of inpatient hospital care. In contrast, only 30% of outpatient services is provided in the public sector, with majority of primary care services provided in the private sector [14]. With a large proportion of medical services offered by the public sector, the Hospital Authority is a statutory body that manages all public hospitals and clinics including general outpatient clinics (GOPCs) and specialist outpatient clinics (SOPCs) in Hong Kong. GOPCs provide care to patients living with chronic diseases with stable conditions and those suffering from mild episodic diseases. If necessary, GOPCs or private family doctors may make referrals to SOPCs for specialist consultation, treatment and investigation. Geriatric Day Hospitals are ambulatory care facilities which provide multidisciplinary assessment, continuous care and rehabilitation to community-dwelling older adults. The government heavily subsidized these public services (over 80%) [15] that patients usually pay at very low prices (Table 1) [16]. For example, fee of each GOPC visit is HKD 50 (USD 6.4), compared to HKD 790 (USD 101.3) for first private outpatient visit. Recipients of the Comprehensive Social Security Assistance and the Higher Old Age Living Allowance can access public healthcare services for free [17]. On the other hand, patients have to pay the charges of private healthcare services with out-of-pocket expenses. Older adults, particularly those economically disadvantaged or living with chronic conditions, tend to attend publicly funded healthcare institutions [18]. The longest waiting time for stable new case booking at SOPCs were 157 weeks for Medicine and 133 weeks for Surgery in the year of 2019/20 [19].
Table 1. Charges of public and private healthcare services (in Hong Kong Dollars)
|
|
Public
|
Private
|
Accident & Emergency
|
$180 per visit
|
-
|
Inpatient (acute)
|
$75 admission fee
$120 per day
|
$6,650 per day (1st class)
$4,430 per day (2nd class)
|
Inpatient (others)
|
$100 per day
|
$6,120 per day (1st class)
$4,080 per day (2nd class)
|
Inpatient medical attendance
|
-
|
$680 - $2,780 per specialty visit
|
Outpatient
|
$50 per visit (general)
$135 for first visit, $80 for subsequent visit (specialist)
|
$790 - $2,210 for first visit
$640 - $1,990 for subsequent visit
|
Geriatric day hospital
|
$60 per visit
|
-
|
Note:
a 1 United States Dollar = 7.8 Hong Kong Dollars
b The charges were effective on 18 June 2017.
c Starting from 1 Jun 2018, Higher Old Age Living Allowance recipients who aged 75 or above are waived for charges for public healthcare services.
Charges of public outpatient services include medication and consultation fee.
The figures were retrieved from website of Hospital Authority of Hong Kong: https://www.ha.org.hk/visitor/ha_visitor_index.asp?Content_ID=10045&Lang=ENG
With the increase in demand and costs associated with both population ageing and technological advances [20], there is an urgent need to re-orient healthcare services towards the provision of primary care and preventive services. Nonetheless, the Hong Kong public does not recognize the importance of primary care and disease prevention [21]. As shown in Figure 1, preventive care shares small proportions of health expenditure in both public and private sectors [20]. In addition, Hong Kong citizens are used to shopping around the private market, rather than developing continuous doctor-patient relationships [21]. While public hospitals and clinics share the same electronic patient record system, most of the individual private healthcare providers keep patient data in paper form. A lack of data sharing often results in fragmented care.
Public-private partnership (PPP) has been adopted by numerous countries to improve health care. Typical examples are infectious disease control programmes in developing regions [22]. HA in Hong Kong has designed several PPP models which purchase services from the private sector in order to enhance patients’ access to healthcare especially chronic condition management. Examples include the Cataract Surgeries Programme, the Colon Assessment PPP, and the Glaucoma PPP [23]. The patients can receive the private services with a fee same as HA one. To promote primary care and the concept of family doctor, the Hong Kong government introduced a PPP programme namely the Elderly Health Care Voucher (EHCV) Scheme in 2009. The scheme offers older adults the voucher as financial incentives to choose private primary healthcare services that meet their needs, including preventive care [24]. A three-year pilot program of the scheme provided five vouchers, each worth HKD 50 (USD 6.4), to older adults aged 70 or above annually. However, the voucher of a limited amount was unsuccessful in encouraging the use of private primary care services [25]. The Hong Kong government has therefore enhanced the annual voucher amount from HKD 250 (USD 32.2) in 2009 to the HKD 2000 (USD 258.0), with a face-value at HKD 1 instead of the original HKD 50 each. The eligible age has been lowered from 70 to 65 since 2017. Recipients can pick over a wide range of healthcare professionals, including general practitioners, family medicine specialists, and Chinese medicine practitioners. The scheme aims to promote preventive care and to develop continuity of care for chronic disease management.
A systematic review shows that voucher programmes could increase healthcare service utilization, improve quality of care, and improve population health outcomes in developing countries [26]. For instances, vouchers improved maternity services in Bangladesh, Cambodia, China and India, family planning services in Kenya, Korea and Taiwan, and sexual and reproductive health care in Nicaragua. The United Kingdom National Health Service also offers an optical voucher to the children under 18 mainly for covering the cost of glasses or contact lenses. However, experience of voucher use in developed world is minimal. There is also no voucher scheme aiming to strengthen primary care services in the rest of the world. Moreover, the EHCV is a community-based voucher which can be used for a wide range of healthcare providers, whereas most other voucher schemes and PPP are service-specific. Research on the EHCV may achieve a new understanding of the voucher use and the PPP models.
Recent local studies revealed that the EHCV in Hong Kong may facilitate the use of private healthcare services, there was no significant reduction in the use of public services [27, 28]. These studies did not assess the impact of the scheme on various aspects of primary care, such as continuity of care and preventive care among older adults with chronic conditions. As a secondary analysis of the Elderly Health Care Quality Survey, this study aimed to examine whether voucher use was associated with (1) a shift of healthcare burden from the public to the private sector, (2) increased utilization of preventive healthcare services, and (3) continuous doctor-patient relationships. These three outcomes are in line with the original goals of the EHCV scheme set by the local government. Our study findings may demonstrate whether a voucher scheme can strengthen primary care in a two-tier healthcare system.