Barriers to entry and the self-regulating profession: Evidence from the market for Italian accountants

This paper provides a systematic study of the market for accountants in Italy during the period 1980-91. Firstly, it develops a comparison in the determinants of incomes of the two competing professions (Commercialisti and Ragionieri) focusing on entry as one of the main variables of interest to explain some stylised facts and trends in the profession itself. Second, we carry out an empirical analysis using panel data to test the effects of self-regulation, in terms of discretion in the admission policy in the profession, on incomes. Our results confirm that the institutional barrier to entry is effective in generating economic rents; furthermore, we show that admission rates are an endogenous variable strongly influenced by past level of incomes

Barriers to Entry and the Self-Regulating Profession

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Proposte per una revisione del finanziamento e dell’offerta dei servizi odontoiatrici in Italia. L’intervento pubblico e i fondi integrativi.

Le cure odontoiatriche sono una componente di rilievo in un servizio sanitario ispirato al principio della globalità assistenziale. Tuttavia, i volumi di prestazioni odontoiatriche erogate dal servizio sanitario sono relativamente modesti e il 90% della spesa odontoiatrica privata è costituita da pagamenti diretti interamente a carico dei pazienti. Vi sono quindi problemi di disuguaglianza nell’accesso alle cure odontoiatriche. Dal lato dell’offerta le strutture sono parcellizzate con prevalenza di studi con pochi professionisti. L’entrata di nuovi soggetti imprenditoriali dall’estero e il fenomeno del turismo odontoiatrico sembrano introdurre incentivi a ridurre la frammentazione e ad adottare nuovi modelli organizzativi. La ricerca intende approfondire le possibilità di un’estensione dell’accesso alle cure odontoiatriche favorendo una riorganizzazione della domanda, modificando la regolamentazione dell’offerta e incentivando i meccanismi di finanziamento integrativi alle disponibilità del servizio sanitario pubblico. Infine, vengono analizzati diversi modelli di fondi integrativi aperti e la loro efficacia nell’ampliare il grado di copertura complessivo del rischio odontoiatrico.assistenza odontoiatrica; fondi integrativi; Lea odontoiatrici; fondi aperti; incentivi fiscali

Electoral mechanisms and pressure groups: The mix of direct and indirect taxation

This paper describes the fiscal structure of a community as an equilibrium of a non-cooperative game where members of different pressure groups - characterised by conflicting interests - compete to get distributive gains. Their interaction is regulated by a constitution which sets the electoral rules and the institutional framework in which pressure groups' activities take place. We focus on how the equilibrium mix of direct and indirect taxation is determined in a community divided into two groups working in different sectors which we label regular and shadow sectors, respectively. Our main aim is to investigate the relations between the relative scale of the shadow sector, the fiscal equilibrium between direct and indirect taxation, and the constitutional setting. In this respect we show that the constitutional settings in which the main legislative body is chosen through a strictly proportional electoral rule tend to determine a fiscal equilibrium with a greater emphasis on direct taxation and this in turn gives greater incentives to enlarge the shadow sector. The paper provides empirical evidence on 21 OECD countries for the period 1970-90 on the relevance of the features of the electoral mechanisms on the fiscal mix between direct and indirect taxation

Are bad health and pain making us grumpy? An empirical evaluation of reporting heterogeneity in rating health system responsiveness

This paper considers the influence of patients’ characteristics on their evaluation of a health system’s responsiveness, that is, a system’s ability to respond to the legitimate expectations of potential users regarding non-health enhancing aspects of care (Valentine et al. 2003a). Since responsiveness is evaluated by patients on a categorical scale, their selfevaluation can be affected by the phenomenon of reporting heterogeneity (Rice et al. 2012). A few studies have investigated how standard socio-demographic characteristics influence the reporting style of health care users with regard to the question of the health system’s responsiveness (Sirven et al. 2012, Rice et al. 2012). However, we are not aware of any studies that focus explicitly on the influence that both the patients’ state of health and their experiencing of pain have on the way in which they report on system responsiveness. This paper tries to bridge this gap by using data regarding a sample of patients hospitalized in four Local Health Authorities (LHA) in Italy’s Emilia-Romagna region between 2010 and 2012. These patients have evaluated 27 different aspects of the quality of care, concerning five domains of responsiveness (communication, social support, privacy, dignity and quality of facilities). Data have been stratified into five sub-samples, according to these domains. We estimate a generalized ordered probit model (Terza, 1985), an extension of the standard ordered probit model which permits the reporting behaviour of respondents to be modelled as a function of certain respondents’ characteristics, which in our analysis are represented by the variables “state of health” and “pain”. Our results suggest that unhealthier patients are more likely to report a lower level of responsiveness, all other things being equal, while patients experiencing pain are more likely to make use of the extreme categories of responsiveness, that is, to choose the category “completely dissatisfied” or the category “completely satisfied”. These results hold across all five domains of responsiveness

GPs and hospital expenditures. Should we keep expenditure containment programs alive?

Pay-for-performance programs offering additional payments to GPs can be used not only to improve the quality of care but also for cost containment purposes. In this paper, we analyse the impact of removing financial incentives in primary care that were aimed at containing hospital expenditure in the Italian region of Emilia Romagna during the period 2002-04. Our analysis draws on regional databanks linking GPs’ characteristics to those of their patients (including all sources of public payments made to GPs), together with information on the utilisation of hospital services. We employ a difference-in-difference specification to assess changes in expenditures for avoidable and total hospital admissions. We identify the treatment group with GPs operating in districts where the program is withdrawn during the observation period (“Leavers”). Their performance is compared to that of two separate control groups, namely: GPs working in districts that grant incentives for the entire period (“Stayers”), and those working in districts that never introduced measures for the containment of hospitalisations (“Non Participants”). The comparison between treatment and control groups shows that removing incentives does not result in a worse performance by Leavers compared to both control groups. This supports the policy of removing incentives, as such entail extra payments to GPs which, however, do not seem capable of significantly influencing their behaviour in the desired ways. Our findings complement previous evidence from the same institutional context showing that only those programs that aim to improve disease management for specific conditions - rather than to simply contain expenditure - have proven successful in reducing avoidable admissions for the target population

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different Diagnosis Related Groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia-Romagna, we test whether a one-year increase in DRG prices induced public hospitals to increase their volume of activity, and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the two years after the policy change than in later years, and for providers with a lower excess capacity in the pre-policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices either decreased or had no impact on the proportion of patients waiting more than six months. Finally, we find no evidence of a significant effect on patients’ average length of stay

Incentives In Primary Care and Their Impact on Potentially Avoidable Hospital Admissions

Financial incentives in primary care have been often introduced with the purpose of improving appropriateness of care and containing demand. We usually observe pay-for-performance programs, but alternatives have been also implemented, such as pay-for-participation in improvement activities and pay-for-compliance with clinical guidelines. Here, we assess the influence of different programs which ensure extra-payments to GPs, for containing episodes of avoidable hospitalisations. Our dataset covers patients and GPs of the Italian region Emilia-Romagna for year 2005, and we control for a wide range of factors potentially influencing GPs’ behaviour. By separating pay-for-performance from pay-for-participation and pay-for-compliance programs, we estimate the impact on the probability of (inappropriate) hospitalisation of financial incentives included in contracts between GPs and the NHS. As dependent variable, we consider two different sets of conditions, for both of which timely and effective primary care should be able to limit the need of hospital admission. The first is based on 27 medical DRGs that Emilia-Romagna identifies as at risk of inappropriateness in primary care, while the second refers to the internationally recognised ACSCs (ambulatory care-sensitive conditions). We show that pay-for-performance schemes may have a significant effect over aggregate indicators of appropriateness, while the effectiveness of pay-for-participation schemes is adequately captured only by taking into account subpopulations affected by specific diseases. Moreover, the same incentive scheme has fairly different effects on the two sets of indicators used, with performance improvements limited to the target explicitly addressed by the policy maker (i.e. the list of 27 DRGs). This evidence is consistent with the idea that a “tunnel vision” effect may occur when public authorities promote and monitor specific sets of objectives, as proxies for more general improvements in health care practices

La responsiveness dei sistemi sanitari: un’analisi empirica sull’assistenza ospedaliera nel Servizio Sanitario Regionale dell’Emilia Romagna

The release of the World Health Report 2000 has brought to the fore the concept of responsiveness as an indicator of health system performance. Responsiveness relates to a system’s ability to respond to the legitimate expectations of potential users about non-health enhancing aspects of care (Valentine et al. 2003). A few studies have investigated how standard socio-demographic characteristics (such as income or education) have an influence on the evaluation of responsiveness by health care users (Puentes Rosas et al. 2006, Sirven et al. 2012, Rice et al. 2012). However, we are not aware of any study investigating the relationship between the frequency with which patients use health services and their evaluation of responsiveness. This paper narrows this gap by using data regarding a sample of patients hospitalized in 9 hospitals of Emilia Romagna, a Region of Italy. The data have been collected by the Agency for Health Care and Social Services of Emilia Romagna between January 2010 and December 2012. We investigate a representative sample of about 2500 in-patients, who have been asked to evaluate 29 different aspect of quality of care which refer to 6 domains of health system responsiveness (communication, social support, privacy, dignity, waiting times and quality of facilities). We make use of this structure of the data by adopting a panel data regression model. The adoption of a panel model helps in controlling for individual heterogeneity, which otherwise could bias our results. Given that responsiveness is evaluated on an ordinal and categorical scale (going from “very dissatisfied” to “very satisfied”) we estimate a panel ordered logit model. Our results suggest that if patients have already been hospitalized in the same ward over the last 5 years they evaluate responsiveness more positively compared to patients who have never been hospitalized before. However, this effect is statistically significant only if patients have been hospitalized in the last 6 months. More generally, the use of a proper methodology to investigate responsiveness at hospital level can allow a better identification of area of intervention for investments in staff training; moreover, it can allow to modify hospital characteristics which have a negative impact on patients’ reporting of responsiveness

Model Predictive Control (MPC) for Enhancing Building and HVAC System Energy Efficiency: Problem Formulation, Applications and Opportunities

In the last few years, the application of Model Predictive Control (MPC) for energy management in buildings has received significant attention from the research community. MPC is becoming more and more viable because of the increase in computational power of building automation systems and the availability of a significant amount of monitored building data. MPC has found successful implementation in building thermal regulation, fully exploiting the potential of building thermal mass. Moreover, MPC has been positively applied to active energy storage systems, as well as to the optimal management of on-site renewable energy sources. MPC also opens up several opportunities for enhancing energy efficiency in the operation of Heating Ventilation and Air Conditioning (HVAC) systems because of its ability to consider constraints, prediction of disturbances and multiple conflicting objectives, such as indoor thermal comfort and building energy demand. Despite the application of MPC algorithms in building control has been thoroughly investigated in various works, a unified framework that fully describes and formulates the implementation is still lacking. Firstly, this work introduces a common dictionary and taxonomy that gives a common ground to all the engineering disciplines involved in building design and control. Secondly the main scope of this paper is to define the MPC formulation framework and critically discuss the outcomes of different existing MPC algorithms for building and HVAC system management. The potential benefits of the application of MPC in improving energy efficiency in buildings were highlighted