in the Netherlands

Using data for 2003, we find that both for non-emergency orthopaedic care (38%) and neuro surgery (54%) numerous Dutch patients did not visit the nearest hospital. Our estimation results show that extra travel time negatively influences the probability of hospital bypassing. Good waiting time performance by the nearest hospital also significantly decreases the likelihood of a bypass decision. Patients seem to place a lower negative value on extra travel time for ortho paedic care than for neurosurgery. The valuation of shorter waiting time also varies between these two types of hospital care. A good performance of the nearest hospital on waiting time decreases the likeli hood of a bypass decision most for neurosurgery. In both samples, patients are more likely to bypass the nearest hospital when it is a university medical centre or a tertiary teaching hospital. Patient attributes, such as age and social status, are also found to significantly affect hospital bypassing. From our analysis it follows that both patient and hospital care heterogeneity should be taken into account when assessing the sub stitutability of hospitals.