Substantial research has been conducted investigating patterns of care delivery, for example, comparing the relative effectiveness of specialists and generalists, and the substitution of care provided by specialists in general-practice settings for hospital-based outpatient care. Treatment loci affect health care aspects including patient satisfaction, health care expenditures and quality outcomes. Locus can be of particular significance for patients with chronic diseases requiring frequent contact with health care systems. In many countries, ongoing monitoring of chronic disease patients can be done at various treatment loci with varying levels of specialization. An obvious hypothesis is that quality of care is higher with higher specialization, while costs are lower in less specialized treatment loci. While health quality outcomes ‘should’ be the primary deciding factor in a world of unlimited resources, healthcare delivery costs are of urgent concern for real-world payers. Evidence generally supports the benefits of specialists’ involvement in treating diabetes, so for a policymaker to willingly accept lower expected health quality in exchange for health care expenditure reductions, by allocating treatment away from specialist towards generalists, it is critical that they can truly expect financial savings. Otherwise there would be a definite loss of efficiency. We use the Danish policy to move the treatment locus for a non-trivial number of type 2 diabetes patient as validation that treatment locus is subject to some degree of randomness. This means that some hospital-monitored patients do not differ meaningfully from some GP-monitored patients, which reduces the selection problem present when comparing cost differences between treatment loci of different levels of specialization. In this study we find that risk-group 2 hospital-monitored type 2 diabetes patients face higher total health care costs – even after controlling for endogeneity of treatment locus. The higher costs are mainly based on higher outpatients- and nonhospital-specialist costs, whereas no significant differences are observed for medication and in patient costs. As expected, costs from GP visits are lower for hospital-monitored patients. Quality, as measured by emergency hospitalizations, shows no significant benefit for our hospital-monitored patient population. Although the truth would be an empirical matter for each concerned individual, this analysis supports the expectation that moving responsibility for care of many type 2 diabetes patients who have been cared for at specialist hospital-based outpatient clinics back to primary care will reduce total healthcare expenditures while taking endogeneity of treatment locus into account. While this evidence also does not indicate that there would be a quality loss on average, and therefore this would be an efficient policy, it remains true that specialist-based care likely provides a true quality benefit for some patients included in our definition of moderate-disease type 2 diabetes. Top-down policies mandating movement of care responsibility of an arbitrary number of patients from a ‘more expensive’ to a ‘less expensive’ treatment locus risk failing to achieve both their financial goals and making health care systems more inefficient. To increase the likelihood of efficient decision making, sufficiently robust evidence of expected cost-savings and expected health impacts should precede implementation of such policies. Reporting suggests that movement of responsibility for type 2 diabetes patients out of the hospital sector, attempting to honour the contractual obligation, has been slower than necessary to fully meet the target within the contract period.
health, diabetes, cost and quality