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

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

Standardising policy and technology responses in the immediate aftermath of a pandemic: a comparative and conceptual framework

Background: The initial policy response to the COVID-19 pandemic has differed widely across countries. Such variability in government interventions has made it difficult for policymakers and health research systems to compare what has happened and the effectiveness of interventions across nations. Timely information and analysis are crucial to addressing the lag between the pandemic and government responses to implement targeted interventions to alleviate the impact of the pandemic. Methods: To examine the effect government interventions and technological responses have on epidemiological and economic outcomes, this policy paper proposes a conceptual framework that provides a qualitative taxonomy of government policy directives implemented in the immediate aftermath of a pandemic announcement and before vaccines are implementable. This framework assigns a gradient indicating the intensity and extent of the policy measures and applies the gradient to four countries that share similar institutional features but different COVID-19 experiences: Italy, New Zealand, the United Kingdom and the United States of America. Results: Using the categorisation framework allows qualitative information to be presented, and more specifically the gradient can show the dynamic impact of policy interventions on specific outcomes. We have observed that the policy categorisation described here can be used by decision-makers to examine the impacts of major viral outbreaks such as SARS-CoV-2 on health and economic outcomes over time. The framework allows for a visualisation of the frequency and comparison of dominant policies and provides a conceptual tool to assess how dominant interventions (and innovations) affect different sets of health and non-health related outcomes during the response phase to the pandemic. Conclusions: Policymakers and health researchers should converge toward an optimal set of policy interventions to minimize the costs of the pandemic (i.e., health and economic), and facilitate coordination across governance levels before effective vaccines are produced. The proposed framework provides a useful tool to direct health research system resources and build a policy benchmark for future viral outbreaks where vaccines are not readily available

Dealing with minor illnesses: the link between primary care characteristics and First Aid Clinics’ attendancesA

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments to community-based alternatives has determined a variety of organisational solutions aimed at reducing the ED overcrowding. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a First-aid clinic (FaC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospital’s ED. We examine the link between the utilisation rates of the FaC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the younger cohorts are heavy users of the FaC and that the extension of practice opening hours significantly lowers the number of attendances, after controlling for GP’s and practice’s characteristics