Spatial effects in hospital expenditures: a district level analysis

Geographical clusters in health expenditures are well documented and accounting for spatial interactions may contribute to properly identify the factors affecting the use of health services the most. As for hospital care, spillovers may derive from strategic behaviour of hospitals and from patients’ preferences that may induce mobility across jurisdictions, as well as from geographically-concentrated risk factors, knowledge transfer and interactions between different layers of care. Our paper focuses on a largely overlooked potential source of spillovers in hospital expenditure: the heterogeneity of primary care providers’ behaviour. To do so, we analyse expenditures associated to avoidable hospitalisations separately from expenditures for highly complex treatments, as the former are most likely affected by General Practitioners, while the latter are not. We use administrative data for Italy’s Region Emilia Romagna between 2007 and 2010. Since neighbouring districts may belong to different Local Health Authorities (LHAs), we employ a spatial contiguity matrix that allows to investigate the effects of geographical and institutional proximity and use it to estimate Spatial Autoregressive and Spatial Durbin Models

GMM estimation of fiscal rules: Monte Carlo experiments and empirical tests

This paper focuses on the estimation of fiscal response functions for advanced economies and on the performance of alternative specifications of the Generalized Method of Moments (GMM) estimator for the rule’s parameters. We first estimate the parameters on simulated data through Monte Carlo experiments; we then run an empirical test on data for the European Monetary Union (EMU). We estimate both the Cyclicallyadjusted primary balance (CAPB) and the Primary balance (PB) models, and check the robustness of the estimates to different specifications of the GMM estimator and to alternative settings of the parameters. We also compare alternative instrument reduction strategies in a context where several endogenous variables enter the model. We find that the system GMM estimator is the best-performing in this framework and the high instrument count comes out not to be problematic. We also make the algebraic links between the parameters in the CAPB and in the PB models explicit, suggesting an effective strategy to estimate the discretionary fiscal response from the coefficients of the PB model. In the empirical application on a dataset for EMU Countries, we find that the evidence of a-cyclicality of discretionary policies is robust to all the specifications of the GMM estimator

Does the extension of primary care practice opening hours reduce the use of emergency services?

Over-crowding in Emergency Departments (EDs) generates potential inefficiencies. Using regional administrative data, we investigate the impact of an increase in the accessibility of primary care on ED visits in Italy. We test whether extending practice opening hours up to 12 hours/day reduces inappropriate ED visits. We estimate count data models, considering different measures for ED visits recorded at the list level. Since the extension programme is voluntary, we also account for the potential endogeneity of participation, using a two-stage residual inclusion and a GMM approach. Our results show that improving primary care accessibility favours a more appropriate use of EDs

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

Civic Capital and Service Outsourcing: Evidence from Italy

This paper studies whether civic capital (those persistent shared beliefs and values that help a group overcome the free rider problem in the pursuit of socially valuable activities) acts an effective restraint against opportunistic behavior in transactions by looking at the firm-level degree of service outsourcing in Italy. Our results show that firms tend to outsource more services in areas where civic capital is higher. We claim that the rise in the propensity to engage in transactions with outside service suppliers stems from the decrease in opportunism between the parties involved. We consider a dynamic specification which allows to disentangle state dependence of service out- sourcing from firm-level heterogeneity, and we use historical instruments to address the potential endogeneity of civic capital

Civic Capital and Service Outsourcing: Evidence from Italy.

This paper studies whether civic capital (those persistent shared beliefs and values that help a group overcome the free rider problem in the pursuit of socially valuable activities) acts an effective restraint against opportunistic behavior in transactions by looking at the firm-level degree of service outsourcing in Italy. Our results show that firms tend to outsource more services in areas where civic capital is higher. We claim that the rise in the propensity to engage in transactions with outside service suppliers stems from the decrease in opportunism between the parties involved. We consider a dynamic specification which allows to disentangle state dependence of service out- sourcing from firm-level heterogeneity, and we use historical instruments to address the potential endogeneity of civic capital