Estimating the costs of specialised care

In most sectors of the economy, specialisation is associated with lower costs. Yet some specialised hospitals claim to require more generous funding than general hospitals. This claim is based on the assertion that their patients are different, and that these differences outweigh the cost advantages of specialisation. Unless the basis for this claim can be established, the financial incentives introduced by Payment by Results to encourage cost reducing behaviour will be diluted.

Essays in health economics and in development

How is medical technology affecting costs growth? Evidence from a panel of US hospitals. In questo articolo misuriamo l’impatto dell’innovazione tecnologica sui costi degli ospedali statunitensi. Le indagini campionarie dell’American Hospital Association (AHA) ci permettono di identificare la disponibilità di determinate tecnologie all’interno dei singoli ospedali, mentre dai rapporti di costo di Medicare reperiamo i dati di natura finanziaria. Definiamo un nuovo indice di disponibilità di macchinari, procedure e processi che permette di evitare l’assunzione di innovazioni tecnologiche egualmente distribuite fra tutti gli ospedali. Per mezzo di un semplice modello di variabili binarie, siamo in grado di identificare sia quelle innovazioni che provocano una riduzione o un incremento dei costi sia lo sviluppo temporale di tali effetti. Complessivamente le nostre stime confermano un fatto generale di publico dominio, che la tecnologia sta comportando un notevole aumento dei costi ospedalieri. Ten years of DRG reform. An empirical analysis of the influence of specialization, productive structure and ownership form on italian hospitals technical efficiency. In questo articolo studiamo come struttura produttiva e specializzazione influiscano sull’efficienza tecnica degli ospedali della regione Lazio, attraverso l’analisi di un campione longitudinale di durata pari a sei anni (2000/2005) derivato dalle schede di dimissione ospedaliera e dalla banca dati del Ministero della Salute. Adottiamo un approccio di funzioni distanza, implementato con tecniche di frontiere stocastiche atte a misurare il livello di efficienza tecnica. Dopo aver controllato per fattori "ambientali" e complessit`a ospedaliera, osserviamo che l'inefficienza è negativamente associata con il grado di specializzazione e positivamente con quello di capitalizzazione. Il più elevato rapporto capitale-lavoro risulta essere tipico delle strutture private, le quali in media fanno un uso meno efficiente delle risorse a loro disposizione rispetto agli ospedali pubblici e a quelli a loro assimilati. Infine, l’analisi delle elasticità di scala mette in evidenza la presenza di economie di scala non sfruttate, che sembra suggerire un intervento di centralizzazione / ristrutturazione delle operazioni. Within households effects of expanding rural nonfarm sector in a developing country. Questo articolo studia gli effetti all'interno delle famiglie dell'espansione del settore non agricolo rurale (RNF) in Ghana. Ci domandiamo se la crescita del settore RNF permetta economie di diversificazione/scopo all'interno delle aziende agricole e come questo influisca sulla domanda di input delle famiglie. Studiamo le connessioni all'interno delle famiglie tra attività agricole e non agricole rurali, dapprima assumendo mercati degli input e degli output perfettamente concorrenziali, e in secondo luogo ipotizzando fallimenti di mercato, in particolare del mercato del lavoro e del credito. Misuriamo queste connessioni attraverso una funzione distanza orientata agli input a livello delle famiglie. Esistono forti complementarietà di costo tra il settore agricolo e non agricolo rurale, soprattutto per le colture da sussistenza, nelle quali le famiglie più povere tendono a specializzarsi. L'espansione del settore RNF aumenta la domanda per la maggior parte degli input, incluso il fattore terra a scopi agricoli

Evaluation of Lesotho’s Child Grants Programme (CGP) and​ Sustainable Poverty Reduction through Income, Nutrition and Access to Government Services (SPRINGS) project

Social protection has been recognized as a key strategy to address poverty, vulnerability and social exclusion in Lesotho. As a result, the Government, with support from UNICEF and the European Union, developed the Child Grants Programme (CGP), which provides unconditional cash transfers to poor and vulnerable households registered in the National Information System for Social Assistance (NISSA). The quantitative impact evaluation presented in this report seeks to document the welfare and economic impacts of CGP and SPRINGS on direct beneficiaries and assess whether combining the cash transfers with a package of rural development interventions can create positive synergies at both individual and household level, especially in relation to income generating activities and nutrition. This paper is being published in the context of a partnership between FAO, IFAD and the Universidad de los Andes (UNIANDES) and its Centro de Estudios en Desarrollo Económico (CEDE) based in Bogotá, Colombia

The Household and Individual-Level Productive Impacts of Cash Transfer Programs in Sub-Saharan Africa

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Cash transfers and women's economic inclusion

This paper investigates whether an increase in exogenous income through the Child Grants model of the Social Cash Transfer programme in Zambia fosters economic inclusion among rural women. We conceptualize economic inclusion as a transformative process comprised of four pillars: productive capacity, financial inclusion, social power, and psychological assets. Using experimental data, we find strong evidence of direct impacts of the Child Grant on the productive capacity, financial inclusion, and psychological assets of rural women. In addition to these direct impacts, we implement a mediation analysis to explore the potential mediating role of psychological assets in affecting the other pillars of economic inclusion. Through this approach, we find indicative evidence of indirect and mutually reinforcing relationships between changes in psychological assets brought about through the Child Grant and improvements in the productive capacity and financial inclusion of beneficiaries. Such results suggest that cash transfers might be effective in promoting women’s economic inclusion, both through the direct monetary effect and through the mediated effect of psychological assets

Is Graduation from Social Safety Nets Possible? Evidence from Sub?Saharan Africa

In the last decade social cash transfer programmes have become extremely popular in sub?Saharan Africa, and are often portrayed as an instrument that can facilitate graduation out of poverty. The evidence on whether social cash transfers have had actual effects on graduation, however, is limited. This article provides a cross?country reflection of the potential effects of social cash transfers on graduation, drawing from impact evaluation results of cash transfer programmes in Ghana, Kenya, Lesotho and Zambia. We analyse whether social cash transfers have improved the likelihood of graduation, through increased productivity, income generation and resilience to shocks. We identify which factors in terms of programme implementation and household characteristics can increase the likelihood of cash transfer programmes facilitating graduation from poverty

Estimating the costs of specialised care

In most sectors of the economy, specialisation is associated with lower costs. Yet some specialised hospitals claim to require more generous funding than general hospitals. This claim is based on the assertion that their patients are different, and that these differences outweigh the cost advantages of specialisation. Unless the basis for this claim can be established, the financial incentives introduced by Payment by Results to encourage cost reducing behaviour will be diluted. We estimate various multiple regressions in order, firstly, to establish the extent to which the receipt of specialised care is associated with higher treatment costs and, secondly, to evaluate hospital performance in controlling costs. We explore how robust the results are to a range of analytical choices by conducting various sensitivity analyses. We use the Hospital Episode Statistics and Reference Cost databases to analyse the characteristics and costs of all patients treated in the NHS during 2008/9. Patients are identified as having received specialised care on the basis of specific diagnostic and procedure codes recorded in their medical record. These codes are agreed by clinicians and form the Specialised Services National Definition Sets. We estimate multiple regression models to assess the extent to which receipt of specialised care increases the cost of treatment. We test the robustness of results to choices about how costs are calculated, how the regression models are specified and how patients are identified as having received specialised care. In addition we assess each hospital’s relative efficiency in controlling costs, after allowing for differences in factor prices and a wide range of patient characteristics. We find that, after allowing for the hospital in which treatment is provided, costs are higher than for other patients allocated to the same Healthcare Resource Group (HRG) if a patient receives one of the following types of specialised service: cancer (18% higher cost), spinal (28%), neurosciences (23%), cystic fibrosis (38%), infectious disease (21%), children (20%), rheumatology (13%), vascular diseases (21%), colorectal (21%) and orthopaedic (21%). The implication for Payment by Results is that ‘top-up’ payments for patients with these markers might be made over and above the tariff associated with the HRG to which they are allocated. We recommend that the size of additional top-up amounts to the percentage increase in costs as reported above, these estimates being derived from our preferred model specification. However, different values could be adopted, justified on other grounds. These grounds may include: Transitional arrangements, notably for children’s services, where the recommended value of 20% is substantially lower than the current 78% top-up; Materiality, where an additional top-up would have limited financial consequence for those types of specialised services that are delivered to only a small number of patients; Sensitivity to model specification. The other model specifications generally imply lower top-up values than those recommended above, with the exception of a model that fails to allow for each hospital’s influence on costs

Hospital Variation in Patient-Reported Outcomes at the Level of EQ-5D Dimensions : Evidence from England

•Background. The English Department of Health has introduced routine collection of patient-reported outcome data for selected surgical procedures to facilitate patient choice and increase hospital accountability. However, using aggregate health outcome scores, such as EQ-5D utilities, for performance assessment purposes causes information loss and raises statistical and normative concerns. Objectives. For hip replacement surgery, we explore a) the change in patient-reported outcomes between baseline and follow-up on 5 health dimensions (EQ-5D), b) the extent to which treatment impact varies across hospitals, and c) the extent to which hospital performance on EQ-5D dimensions is correlated with performance on the EQ-5D utility index. Methods. We combine information on pre- and postoperative EQ-5D outcomes with routine inpatient data for the financial year 2009–2010. The sample consists of 21,000 patients in 153 hospitals. We employ hierarchical ordered probit risk-adjustment models that recognize the multilevel nature of the data and the response distributions. The treatment impact is modeled as a random coefficient that varies at the hospital level. We obtain hospital-specific empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each EQ-5D dimension and the EQ-5D utility index and analyze correlations of EB estimates across these. Results. Hospital treatment is associated with improvements in all EQ-5D dimensions. Variability in treatment impact is most pronounced on the mobility and usual activities dimensions. Conversely, only pain/discomfort and anxiety/depression correlate well with performance measures based on utilities. This leads to different assessments of hospital performance across metrics. Conclusions. Our results indicate which hospitals are better than others in improving health across particular EQ-5D dimensions. We demonstrate the importance of evaluating dimensions of the EQ-5D separately for the purposes of hospital performance assessment

Mediation analysis of the impact of the Zimbabwe Harmonized Social Cash Transfer Programme on Food Security and Nutrition

This paper analyses the causal effects of the Zimbabwe Harmonized Social Cash Transfer (HSCT) programme on food security and nutrition after 12 months of implementation. Through mediation analysis, we disentangle the total effect of the programme on its direct effect due to the greater liquidity of beneficiary households, which increases the affordability of food, and its indirect effect mediated by an increase in agricultural activities. We find a total effect of cash transfers on food security and nutrition ranging between a 11 and 16 percent increase with respect to the baseline comparison mean for the household dietary diversity score and number of food items consumed, respectively. Causal mediation analysis shows that most of the effects are driven by the increased liquidity of HSCT beneficiaries. However, approximately between 10 and 21 percent of the total effect is mediated by agricultural activities, suggesting that cash transfer programmes not only play a protective role against food insecurity but also a promoting role towards more diversified nutrition

Cash Transfers and Gender Differentials in Child Schooling and Labor: Evidence from the Lesotho Child Grants Programme

We examine the impacts of an unconditional cash transfer in Lesotho using an experimental impact evaluation design. We find that the cash transfer led to different outcomes for girls and boys, overall favouring secondary school-aged girls. Girls in this age group were less likely to miss school, spent more time at school, and faced a reduced time burden in household chores. While the general results are maintained in households with a married couple present, in de jure female-headed households, outcomes improved among secondary school-aged boys relative to secondary school-aged girls. By contrast, having the mother as cash recipient was not unequivocally linked to better educational outcomes for children. This puts into question the existence of gender preferences in schooling in Lesotho and suggests that impacts on child welfare are influenced by time and labor constraints and by gender-based differences in opportunity costs of a child’s time