Economies of scale and scope: A literature review in the context of hospital mergers

R E S U M O - Perante o atual contexto de contenção de gastos no sector da saúde e consequente preocupação com a eficiência do sistema, tem-se assistido a mudanças várias no modelo de gestão e organizacional do sistema de saúde. Destaca-se a criação de centros hospitalares através de fusões administrativas, sem quaisquer alterações no número de estruturas físicas, apresentando-se como argumentos primordiais o aproveitamento de sinergias e o uso mais eficiente dos recursos disponíveis. Dada a importância desta modalidade organizativa nos últimos anos, foi objetivo do presente estudo perceber os motivos subjacentes ao redimensionamento hospitalar, bem como o seu o impacto nos ganhos de eficiência através do aproveitamento de economias de escala, tendo por base a revisão da literatura. Pretendeu-se ainda analisar as técnicas mais adequadas de avaliação da estrutura de custos dos hospitais, bem como a sua eficiência. A literatura sugere a presença de economias de escala e de diversificação por explorar, mas apenas as fusões entre hospitais de pequena dimensão e de natureza semelhante podem beneficiar destes ganhos de escala.A B S T R A C T - Driven by the current pressure on resources induced by budgetary cuts, the Portuguese Ministry of Health is imposing changes in the management model and organization of NHS hospitals, including the creation of hospital centres as a result of administrative mergers of existing hospitals. According to the political discourse, one of the main goals expected from this measure is the creation of synergies and more efficiency in the use of available resources by adjusting their scale optimisation. Given this active policy of hospital merger, this study intends to describe the underlying reasons and the impact on efficiency gains, by looking at economies of scale namely through reductions in expenditures, based on the literature review. It was also sought to analyse the appropriate techniques to evaluate the hospitals’ efficiency and the cost structure. The literature suggests that there are economies of scale and scope to explore, but only mergers of relatively small and similar hospitals were successful.info:eu-repo/semantics/publishedVersio

Economias de escala em centros hospitalares

RESUMO - Perante o actual contexto de contenção de gastos no sector da saúde e consequente preocupação com a eficiência do sistema, tem‐se assistido a mudanças várias no modelo de gestão e organizacional do sistema de saúde. Destaca‐se a alteração da estrutura hospitalar, com vista à racionalização dos seus recursos internos, onde as fusões hospitalares têm assumido um papel determinante. Em Portugal, nos últimos 10 anos, assistiu‐se a uma significativa redução do número de hospitais (de sensivelmente 90 para 50 unidades), exclusivamente através das fusões e sem quaisquer alterações no número de estruturas físicas existentes. Não obstante os argumentos justificativos desta reforma, a avaliação dos objectivos implícitos é insuficiente. Neste âmbito, pretendeu‐se com este estudo contribuir para a análise do impacte da criação de centros hospitalares na redução de gastos, isto é, verificar se a consolidação e consequente reengenharia dos processos produtivos teve consequencias ao nível da obtenção de economias de escala. Para esta análise usou‐se uma base de dados em painel, onde se consideraram 75 hospitais durante 7 anos (2003‐2009), número que foi reduzindo ao longo do período em análise devido às inúmeras fusões já referidas. Para avaliar os ganhos relativos às fusões hospitalares, ao nível da eficiência técnica e das economias de escala, recorreu‐se à fronteira estocástica especificada função custo translog. Estimada a fronteira, foi possível analisar três centros hospitalares específicos, onde se comparou o período pré‐fusão (2005‐2006) com o período após a fusão (2008‐2009). Como variáveis explicativas, relativas à produção hospitalar, considerou‐se o número de casos tratados e os dias de internamento (Vita, 1990; Schuffham et al., 1996), o número de consultas e o número de urgências, sendo estas variáveis as mais comuns na literatura (Vita, 1990; Fournier e Mitchell, 1992; Carreira, 1999). Quanto à variável dependente usou‐se o custo variável total, que compreende o total de custos anuais dos hospitais excepto de imobilizado. Como principais conclusões da investigação, em consequência da criação dos centros hospitalares, são de referir os ganhos de escala na fusão de hospitais de reduzida dimensão e com mais serviços complementares. --------ABSTRACT - Driven by the current pressure on resources induced by budgetary cuts, the Portuguese Ministry of Health is imposing changes in the management model and organization of NHS hospitals. The most recent change is based on the creation of Hospital Centres that are a result of administrative mergers of existing hospitals. In less than 10 years the number of hospitals passed from around 90 to around 50, only due to the mergers and without any change in the existing number of physical institutions. According to the political discourse, one of the main goals expected from this measure is the creation of synergies and more efficiency in the use of available resources. However, the merger of the hospitals has been a political decision without support or evaluation of the first experiments. The aim of this study is to measure the results of this policy by looking at economies of scale namely through reductions in the expenditures, as expected and sought by the MoH. Data used covers 7 years (2003‐2009) and 75 hospitals, number that has been reduced my the enoumerous mergers during the last decade. This work uses a stochastic frontier analysis through the translog cost function to examine the gains from mergers, which were decomposed into technical efficiency and economies of scale. It was analised these effects by the creation of three specific hospital centers, using a longitudinal approach to compare the period pre‐merger (2003‐2006) with the post‐merger period (2007‐09). To measure changes in inpatient hospital production volume and length of stay are going to be considered as done by Vita (1990) and Schuffham et al. (1996). For outpatient services the number of consultations and emergencies are going to be considered (Vita, 1990; Fournier e Mitchell, 1992; Carreira, 1999). Total variable cost is considered as the dependent variable explained the aforementioned ones. After a review of the literature results expected point to benefits from the mergers, namely a reduction in total expenditures and in the number of duplicated services. Results extracted from our data point in the same direction, and thus for the existence of some economies of scale only for small hospitals

Verdade material e prova no processo administrativo fiscal

Diante da permissividade a todos os tipos de prova legalmente admitidos e moralmente legítimos, algumas espécies são mais evidentes na esfera tributária. A exemplo, a prova direta revela-se bastante contundente. A documental possui larga utilização. A pericial pode conduzir a uma verdade material que bem pode coincidir com a verdade fática. A eletrônica inova a cada momento o Processo Administrativo Fiscal, mas o conjunto probatório convergente é que influenciará o juízo da autoridade julgadora, buscando separar-se aqueles que tributariamente nada devem, daqueles que se utilizam de métodos de sonegação cada vez mais requintados ou dos que cometem práticas criminosas ainda mais ousadas.33 p.Administração PúblicaGestão PúblicaOrçamento e Finança

Verdade material e prova no processo administrativo fiscal

Diante da permissividade a todos os tipos de prova legalmente admitidos e moralmente legítimos, algumas espécies são mais evidentes na esfera tributária. A exemplo, a prova direta revela-se bastante contundente. A documental possui larga utilização. A pericial pode conduzir a uma verdade material que bem pode coincidir com a verdade fática. A eletrônica inova a cada momento o Processo Administrativo Fiscal, mas o conjunto probatório convergente é que influenciará o juízo da autoridade julgadora, buscando separar-se aqueles que tributariamente nada devem, daqueles que se utilizam de métodos de sonegação cada vez mais requintados ou dos que cometem práticas criminosas ainda mais ousadas.33 p.Administração PúblicaGestão PúblicaOrçamento e Finança

A importância do lúdico na Educação Infantil

O presente trabalho tem como objetivo o estudo da Importância do Lúdico na Educação Infantil especialmente para aprendizagem dos alunos, investigando as formas e maneiras de utilizar o lúdico como importante ferramenta de desenvolvimento das crianças de Educação Infantil. Assim como no passado, também nos dias atuais é possível afirmar que o lúdico favorece o desenvolvimento da criança. O lúdico abrange conhecimentos e capacita a criança a interagir no mundo de modo criativo e transformador. A partir de um estudo sobre o desenvolvimento da criança e como ela adquire conhecimento, os educadores que atuam na Educação Infantil e os pais, se aproximam no mundo infantil, construindo uma relação mais significativa. As brincadeiras, jogos e brinquedos fazem parte do contexto da criança em casa, na escola, creche e em todos os momentos do seu cotidiano. Sendo assim, é muito importante que a criança tenha estímulos e que haja oportunidades para que a sua imaginação seja alimentada. O presente estudo traz a constatação de que os pais devem participar das brincadeiras dos seus filhos e incentivar brincadeiras antigas que fazem parte de nossa cultura, como forma de contribuir de forma lúdica na educação infantil. É salutar propiciar à criança condições para seu desenvolvimento cognitivo

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Cost effects of hospital mergers in Portugal

The Portuguese hospital sector has been restructured by wide-ranging hospital mergers, following a conviction among policy makers that bigger hospitals lead to lower average costs. Since the effects of mergers have not been systematically evaluated, the purpose of this article is to contribute to this area of knowledge by assessing potential economies of scale to explore and compare these results with realized cost savings after mergers. Considering the period 2003-2009, we estimate the translog cost function to examine economies of scale in the years preceding restructuring. Additionally, we use the difference-in-differences approach to evaluate hospital centres (HC) that occurred between 2004 and 2007, comparing the years after and before mergers. Our findings suggest that economies of scale are present in the pre-merger configuration with an optimum hospital size of around 230 beds. However, the mergers between two or more hospitals led to statistically significant post-merger cost increases, of about 8 %. This result indicates that some HC become too large to explore economies of scale and suggests the difficulty of achieving efficiencies through combining operations and service specialization