Hotelling competition on quality in the health care market.

This paper aims to theoretically analyse recent health system reforms. Generally patients are free to choose, within the region they live in, the best provider among the private "accredited" and public ones. The criterion patients use to choose the provider which fits their expectations best is not, at least in a tax financed system, the price of the treatment since patients do not pay directly for the treatment they receive. Crucial in determining their choice is the quality level and the provider spatial location. In a normative perspective we want to analyse hospitals' Nash/Counot and Stackelberg equilibriums in a Hotelling spatial competition scenario. Because of asymmetric information, patients could be unable to observe the true quality provided. Thus the demand for health care services is assumed to depend on a perceived quality (different from true quality). New equilibrium outcomes are investigated when patient choice is affected by uncertainty.

It takes three to tango: Soft budget constraint and cream skimming in the hospital care market

Cream skimming is an illegal behaviour that consists in choosing to treat patients according to their ability to recover. It arises from the use of prospective payment schemes in an asymmetry of information framework. In this context in fact the provider can observe some relevant information (freely or at a cost) before making its effort which will then be used to its own advantage. The paper studies the scope for these types of behaviour in a mixed market for hospital care where the hospitals do not share the same objectives. We show that in this context cream skimming is made possible by the presence of two important elements: the public hospital prefers to treat high severity patients and the regulator is unable to enforce hard budget constraint rules. The paper adds an important dimension to the study of cream skimming as proposed by the traditional literature where asymmetry of information alone is considered the cause of this market failure. In our context, in fact, cream skimming arises mainly from a regulatory failure.

Social influence and neighbourhood effects in the health care market.

This work is intended to analyze the market for health care through a computational approach based on unsupervised neural networks. The paper provides a theoretical framework for a computational model that relies on Kohonen's self organizing maps (SOM), arranged into two layers: in the upper layer the competition dynamics of health care providers is modelled, whereas in the lower level patients behaviour is monitored. Interactions take place both vertically between the layers (in a bi-directional way), and horizontally, inside each level, exploiting neighbourhood features of SOM: signals move vertically from hospitals to patients and vice-versa, but they also spread out sideward, from patient to patient, and from hospital to hospital. The result is a new approach addressing the issue of hospital behaviour and demand mechanism modelling, which conjugates a robust theoretical implementation together with an instrument of deep graphical impact.self organizing maps; health market; adaptive behaviour; incomplete information; mixed market

Mean voting rule and strategical behavior: an experiment

This paper considers the problem of voting about the quantity of a public good. An experiment has been run in order to test the extent of the strategic bias that arises in the individual vote when the social choice rule is to select the mean of the quantities voted for; conflicting theoretical predictions are available in the literature on this purpose. The political implications of the mean rule and its e.ects upon e.ciency are also discussed. The role of voters' information is considered. A comparison is made with the working of the median rule.

Migrants and mafia as global public goods

Global public goods, differently from what it might be thought, are quite common in the real world. This work suggests that both the governments' struggle against Mafia and the prevention of immigration can be regarded as global public goods. We assume a federation of jurisdictions with two tiers of Government: the central and the local. Regional utility directly represents the preferences of citizens, since the local governments aim at individualistic utility maximization; central government uses the redistribution of resources among the members of the federation to maximize the social welfare which is given, as usual, by the sum of regional utilities. The Central Government aims at welfare maximization. To get its goal it has to find out the efficient way to fund and provide public goods taking into account not only their particular characteristics but also the fact that, in many circumstances, their production faces increasing cost, which may depend both on the quantity of good produced and on the type (high or low cost) of the producer (which, in this framework, coincides with the jurisdiction). Thus the first issue addressed by the paper concerns the choice between central and local provision. Furthermore, as far as the informational structure is concerned, the centre lacks information concerning the type of each region. Thus, the central government's key informational problem concerns the regional costs and quantities with regard both to the public and the private good. Indeed we assume that the centre can observe the expenditure levels but neither the costs nor the outputs associated with those expenditure levels.global public good, asymmetric information, adverse selection, redistribution, Mafia

Nash behaviour and public good

In this note we analyse the provision of a pure public good with non constant production cost in the context of a federation of jurisdictions with two tiers of Government: the central and the local. The central government aims at welfare maximization but this objective is constrained to the use of lump sum transfer. Local governments aim at their own utility maximization and they behave according to the Nash rule. The production cost for the public good is affected by the jurisdiction's type (high or low) and by the quantity of the good that is produced. It is shown that a social welfare improvement might take place, in some circumstances, even without any central government intervention. On the other hand a first best is unreachable under the hypothesis of Nash behaviour and lump sum transfer among jurisdictions.public good, Nash equilibrium, lump sum transfer

Libertàdi scelta e contratti prospettici: l'asimmetria informativa nel mercato delle cure sanitarie ospedaliere.

The model studies the role of reputation in contracts between providers and purchasers of health care services. The economic literature has examined the case when the demand for health services depends on the quality offered, but because of information asymmetry, we assume that quality is not directly observable by patients. However, patients can obtain information (not perfect) about the provider, i.e. they can observe its reputation. In this paper we suppose that patient demand is influenced by the provider's reputation. The model shows that by a prospective payment contract the purchaser can overcome the quality / cost reducing effort trade off, but optimal levels for all the variables of interest are not achievable. Controlling the payment scheme (fixed price per patient treated) the purchaser can get a second best equilibrium outcome. If the main purchaser's concern is quality, he will obtain that result at the cost of a higher price than in the perfect information scenario. Information asymmetry brings an inefficient solution. Transversality conditions underline the equilibrium outcome when the demand mechanism by reputation is not used: the quality / cost trade off can not be avoided.

Ranking and Prioritization of Emergency Departments Based on Multi-indicator Systems

In this work we discuss how Emergency Departments (EDs) can be ranked on the basis of multiple indicators. This problem is of absolute relevance due to the increasing importance of EDs in regional healthcare systems and it is also complex as the number of indicators that have been proposed in the literature to measure ED performance is very high. Current literature faces this problem using synthetic (or numerically aggregated) indicators of a set of performance measures but, although simple, this solution has a number of drawbacks that make this choice inefficient: a compensation effect among the indicators; a high degree of subjectivism in the indicators weighting; opacity in the decision making; all the EDs are considered to be comparable. Indeed, the situations in which EDs are comparable (i.e. when all the performance of one ED are not lower than the performance indicators of the other) are a minority and incomparability is by itself a source of information that should be used to identify situations for which different policy actions should be designed. In this work we propose to use non compensatory composite indicators and partial ordering theory to rank and compare EDs giving value to the reasons of such an incomparability. These methods are applied on a case study of 19 EDs in an administrative region in Italy. \ua9 2016, Springer Science+Business Media Dordrecht

Is it still worthwhile to perform quarterly CD4+ T lymphocyte cell counts on HIV-1 infected stable patients?

Background: In the last twenty years routine T CD4+ lymphocyte (CD4) cell count has proved to be a key factor to determine the stage of HIV infection and start or discontinue of prophylaxis for opportunistic infections. However, several studies recently showed that in stable patients on cART a quarterly CD4 cell count monitoring results in limited (or null) clinical relevance. The research is intended to investigate whether performing quarterly CD4 cell counts in stable HIV-1 patients is still recommendable and to provide a forecast of the cost saving that could be achieved by reducing CD4 monitoring in such a category of patients. Methods: The study is based on data referring to all HIV-infected patients > 18 years of age being treated at two infectious diseases units located in the metropolitan area of Genoa, Italy. The probability of CD4 cell counts dropping below a threshold value set at 350 cells/mm3 is assessed using confidence intervals and Kaplan-Meier survival estimates, whereas multivariate Cox analysis and logistic regression are implemented in order to identify factors associated with CD4 cell count falls below 350 cells/mm3. Results: Statistical analysis reveals that among stable patients the probability of maintaining CD4 >350 cell/mm3 is more than 98%. Econometric models indicate that HCV co-infection and HIV-RNA values >50 copies/mL in previous examinations are associated with CD4 falls below 350 cells/mm3. Moreover, results suggest that the cost saving that could be obtained by reducing CD4 examinations ranges from 33% to 67%. Conclusions: Empirical findings show that patients defined as stable at enrollment are highly unlikely to experience a CD4 value <350 cell/mm3 in the space/arc of a year. The research supports a recommendation for annual CD4 monitoring in stable HIV-1 patients

What's in a Sign? Trademark Law and Economic Theory

Abstract: The aim of this paper is to summarise the extant theory as it relates to the economics of trademark, and to give some suggestions for further research with reference to distinct streams of literature. The proposed line of study inevitably looks at the complex relationship between signs and economics. Trademark is a sign introduced to remedy a market failure. It facilitates purchase decisions by indicating the provenance of the goods, so that consumers can identify specific quality attributes deriving from their own, or others', past experience. Trademark holders, on their part, have an incentive to invest in quality because they will be able to reap the benefits in terms of reputation. In other words, trademark law becomes an economic device which, opportunely designed, can produce incentives for maximising market efficiency. This role must, of course, be recognised, as a vast body of literature has done, with its many positive economic consequences. Nevertheless, trademark appears to have additional economic effects that should be properly recognized: it can determine the promotion of market power and the emergence of rent-seeking behaviours. It gives birth to an idiosyncratic economics of signs where very strong protection tends to be assured, even though the welfare effects are as yet poorly understood. In this domain much remains to be done and the challenge to researchers is open