Freedom of choice and health services' performance: Evidence from a national health system

Public policies fostering the freedom of choice of provider in the healthcare sector are increasingly common in many countries and regions, where policymakers wish to empower patients and improve health service performance. However, in the literature there is not clear consensus about the impact of expanded patient choice on healthcare quality yet. This study investigates whether increasing patients' freedom of choice influences health system outcomes in terms of various non-clinical aspects of care, a dimension often overlooked by researchers in this field. Our study considers a "natural experiment" that took place within the Spanish National Health System in 2009 under which citizens of the Community (region) of Madrid were allowed to freely choose among any GP and/or specialist in their region. The empirical analysis was conducted by using Spanish microdata for the period 2002-2016 and used synthetic control estimation techniques. The key findings show the reform had a strong and long-lasting impact, reducing average waiting times and increasing patients' satisfaction with the specialist attention received. We did not detect any statistically significant impact of the reform on the other responsiveness domains analysed. Our analysis shows that freedom of choice policies could improve health system performance if they are combined with appropriate economic incentives for health providers.