Waiting Times and Cost Sharing for a Public Health Care Service with a Private Alternative: A Multi-Agent Approach

Cost sharing represent a well-established tool for the control of health care demand in many Oecd countries, even though it is used with caution, and in combination with other instruments, in order to avoid potential negative impacts on access to essential health care services. Waiting lists and waiting times represent an alternative (and implicit) way to control demand in public health care systems, even though rationing by waiting may be an inferior solution to cost-sharing in terms of welfare. This paper focuses on the use of waiting times, cost-sharing, and other tools (in particular, priority and appropriateness criteria) in order to control demand for a public outpatient health service in presence of a fully paid out-of-pocket private alternative. We develop an agent-based model where heterogeneous agents maximise their individual utility based on income and health status. On this basis, we develop some computational experiments based on micro-simulations that offer some useful insights for health care policy. In particular, we show that: i) the presence of a private alternative to public treatment can improve social welfare and health equity in a NHS, when public supply is constrained by a fixed budget and longer waiting times than the private one; ii) using prioritisation of waiting lists without any copayment to control the demand for public treatment may produce high performances in terms of social welfare, health equality and policy efficiency; iii) applying a moderate copayment rate as a tool to control public demand could determine the same policy efficiency of using only priority lists, if the copayment revenues are used to fund the public provision

Measuring Hospitals Efficiency through Data Envelopment Analysis when Policy-makers' Preferences Matter.An Application to a sample of Italian NHS hospital

In this paper we show how both the choice of specific constraints on input and output weights (in accordance with health care policy-makers’ preferences) and the consideration of exogenous variables outside the control of hospital management (and linked to past policy-makers’ decisions) can affect the measurement of hospital technical efficiency using the Data Envelopment Analysis (DEA). Considering these issues, the DEA method is applied to measure the efficiency of 85 (public and private) hospitals in Veneto, a Northern region of Italy. The empirical analysis allows us to verify the role of weight restrictions and of demand in measuring the efficiency of hospitals operating within a National Health Service (NHS). We find that the imposition of a lower bound on the virtual weight of acute care discharges weighted by case-mix (in order to consider policy-maker objectives) reduces average hospital efficiency. Moreover, we show that, in many cases, low efficiency scores are attributable to external factors, which are not fully controlled by the hospital management; especially for public hospitals low total efficiency scores can be mainly explained by past policy-makers’ decisions on the size of the hospitals or their role within the regional health care service. Finally, non-profit private hospitals exhibit a higher total inefficiency while both non-profit and for-profit hospitals are characterised by higher levels of scale inefficiency than public ones

Cost-effectiveness of a melanoma screening programme using whole disease modelling

OBJECTIVE: To assess the potential impact of a melanoma screening programme, compared with usual care, on direct costs and life expectancy in the era of targeted drugs and cancer immunotherapy. METHODS: Using a Whole Disease Model approach, a Markov simulation model with a time horizon of 25 years was devised to analyse the cost-effectiveness of a one-time, general practitioner-based melanoma screening strategy in the population aged over 20, compared with no screening. The study considered the most up-to-date drug therapy and was conducted from the perspective of the Veneto regional healthcare system within the Italian National Health Service. Only direct costs were considered. Sensitivity analyses, both one-way and probabilistic, were performed to identify the parameters with the greatest impact on cost-effectiveness, and to assess the robustness of our model. RESULTS: Over a 25-year time horizon, the screening intervention dominated usual care. The probabilistic sensitivity analyses confirmed the robustness of these findings. The key drivers of the model were the proportion of melanomas detected by the screening procedure and the adherence of the target population to the screening programme. CONCLUSIONS: The screening programme proved to be a dominant option compared with usual care. These findings should prompt serious consideration of the design and implementation of a regional or national melanoma screening strategy within a National Health Service

Global Economic Crisis: Impact and Restructuring of the Services Sector in India

The Indian economy has shown considerable resilience to the global economic crisis by maintaining one of the highest growth rates in the world. The services sector accounted for around 88% of the growth rate in real gross domestic product in 2008-09. To demystify the relatively resilient growth of the services sector in India, this study examines both the demand-side and the supply-side factors that have contributed to its growth To assess the role of external demand, income elasticity of export demand for the aggregated services and some of the disaggregated services of India were estimated. It was found that the main driver of growth in India's services sector is growth in the domestic demand for services and not growth in the export of services. The contribution of the growth of the export of services to the growth of the overall services sector was only 22%. In order to examine the role of supply-side factors, total factor productivity growth was estimated in the services sectors that have contributed substantially to overall growth, which are the software and banking services. Using Data Envelopment Analysis at the firm level, it was found that both these sectors experienced productivity growth above 10% after 2000. High domestic demand and high productivity growth largely explain the resilience of India's services growth

Sostenibilit\ue0 del Servizio sanitario nazionale e fondi sanitari integrativi: un contributo al dibattito

The present work aims to offer a useful reference framework to analyse the functioning mechanism of the National health service (Nhs) and to understand if its financial sustainability could be better guaranteed through the consolidation of a multi-pillar model in which non-profit supplementary health insurance (second pillar) complements the public basic coverage (first pillar). The prospect of a contraction in the share of Gdp allocated by Italy to public health expenditure (also due to the persistence of binding financial constraints) together with the evidence of a private spending largely financed through out-of-pocket payments and essentially without intermediation have led many analysts and politicians to propose an expansion of the role of supplementary health insurance. The phenomenon of supplementary health insurance appears today very complex and articulated and requires a complete reorganization of the legislative and fiscal framework. Supplementary health insurance can effectively represent the second pillar of the Italian health care system \u2013 without compromising the values of universal coverage, solidarity in financing and equity in access on which the Nhs is based \u2013 only if it will be governed effectively, correcting the current distortions and enhancing its potential in terms of social well-being

Ticket e gestione delle liste di attesa per una prestazione specialistica ambulatoriale pubblica in presenza di un’alternativa privata: un modello agent-based

Il presente contributo analizza l’utilizzo dei tempi di attesa, del ticket e di altri strumenti (in particolare, classi di priorità e criteri di appropriatezza) di governo della domanda di una prestazione specialistica ambulatoriale pubblica in presenza di un’alternativa privata a pagamento. Viene sviluppato un modello agent-based in cui agenti (pazienti) eterogenei massimizzano la loro utilità individuale dipendente da reddito, salute e altre caratteristiche individuali. A partire da questo modello, vengono sviluppati alcuni esperimenti computazionali basati su micro-simulazioni con l’obiettivo di offrire indicazioni utili in termini di politica sanitaria. I principali risultati di tali simulazioni possono essere così sintetizzati: 1. la presenza di un’alternativa privata a pagamento può consentire di migliorare il benessere sociale e l’equità nei livelli di salute nel Servizio sanitario nazionale, quando l’offerta pubblica è limitata da un vincolo di bilancio ed è caratterizzata da tempi di attesa più lunghi rispetto al privato; 2. utilizzare unicamente la prioritizzazione delle liste di attesa come strumento di governo della domanda, senza applicare ticket, può consentire di ottenere elevate performance in termini di benessere sociale, equità nei livelli di salute ed efficenza della politica sanitaria; 3. l’applicazione di una compartecipazione moderata può produrre la stessa efficienza ottenuta con la prioritizzazione se le entrate del ticket vengono utilizzate per finanziare un aumento dell’offerta pubblica

Un'analisi dell’efficienza e dei costi delle strutture residenziali per anziani della Regione Veneto

Il lavoro considera la tematica dell'analisi dell'efficienza e dei costi delle strutture residenziali della Regione Veneto. si verifica l'esistenza di economie di scala e si misura il grado di efficienza di costo dei servizi per mezzo di una frontiera di costo stimata con la tecnica Cols (Corrected Least Squares)

Sostenibilit\ue0 del Servizio sanitario nazionale e fondi sanitari integrativi: un contributo al dibattito

Il presente lavoro intende offrire un quadro di riferimento utile per analizzare il meccanismo di funzionamento del Servizio sanitario nazionale (Ssn) e per capire se la sua sostenibilit\ue0 finanziaria pu\uf2 essere meglio garantita attraverso il consolidamento di un modello multi-pilastro in cui fondi sanitari integrativi non profit (secondo pilastro) si affiancano alla copertura di base pubblica (primo pilastro). La prospettiva di una contrazione della quota di Pil destinata dall\u2019Italia alla spesa sanitaria pubblica (anche a causa del permanere di vincoli finanziari stringenti) insieme con l\u2019evidenza di una spesa privata in larga parte sostenuta direttamente dalle famiglie, e sostanzialmente priva di forme di intermediazione, hanno indotto molti analisti e politici a proporre un\u2019espansione del ruolo dei fondi sanitari integrativi. Il fenomeno dei fondi sanitari integrativi appare oggi molto complesso e articolato e richiede un riordino complessivo del quadro normativo e fiscale di riferimento. La previdenza sanitaria integrativa potr\ue0 rappresentare effettivamente il secondo pilastro del sistema sanitario italiano \u2013 senza pregiudicare i valori di copertura universale, solidariet\ue0 nel finanziamento e di equit\ue0 nell\u2019accesso su cui \ue8 fondato il Ssn \u2013 solo se verr\ue0 governata in maniera efficace, correggendo le attuali distorsioni e valorizzando le sue potenzialit\ue0 in termini di promozione del benessere sociale

Analisi dell'efficienza relativa delle strutture di ricovero con il metodo DEA. Il caso degli ospedali del Veneto

Il presente contributo intende analizzare la possibilità di determinare l’efficienza relativa delle strutture di ricovero a livello intra-regionale utilizzando il metodo DEA. Nel paragrafo 2 si esaminano, in termini molto sintetici, le tipologie degli output e degli input utilizzati nell’ambito del processo produttivo dell’ospedale. Nel paragrafo 3 vengono esplicitate le principali implicazioni derivanti dalla scelta della DEA, focalizzando l’attenzione sulle ipotesi alla base di tale metodologia, in particolare rispetto alla tecnologia di produzione e alle preferenze dei managers o delle autorità di politica sanitaria riguardo al mix di output prodotto. Nel paragrafo 4 viene evidenziato come l’eventuale inefficienza degli ospedali possa essere imputabile sia all’utilizzo di una tecnica di produzione non ottimale (inefficienza interna imputabile al management ospedaliero) sia al possibile sovradimensionamento della capacità produttiva rispetto alla domanda espressa (inefficienza esterna imputabile alle scelte di programmazione sanitaria). Nel paragrafo 5, infine, il metodo DEA viene applicato per la misurazione dell’efficienza relativa degli ospedali del Veneto