Essays in Applied Health Economics: Evidence on Health and Health Care in Italy and UK

This thesis is the result of my experience as a PhD student taking part in the Joint Doctoral Programme at the University of York and the University of Bologna. In my thesis I deal with topics that are of particular interest in Italy and in Great Britain. Chapter 2 focuses on the empirical test of the existence of the relationship between technological profiles and market structure claimed by Sutton’s theory (1991, 1998) in the specific economic framework of hospital care services provided by the Italian National Health Service (NHS). In order to test the empirical predictions by Sutton, we identify the relevant markets for hospital care services in Italy in terms of both product and geographic dimensions. In particular, the Elzinga and Hogarty (1978) approach has been applied to data on patients’ flows across Italian Provinces in order to derive the geographic dimension of each market. Our results provide evidence in favour of the empirical predictions of Sutton. Chapter 3 deals with the patient mobility in the Italian NHS. To analyse the determinants of patient mobility across Local Health Authorities, we estimate gravity equations in multiplicative form using a Poisson pseudo maximum likelihood method, as proposed by Santos-Silva and Tenreyro (2006). In particular, we focus on the scale effect played by the size of the pool of enrolees. In most of the cases our results are consistent with the predictions of the gravity model. Chapter 4 considers the effects of contractual and working conditions on selfassessed health and psychological well-being (derived from the General Health Questionnaire) using the British Household Panel Survey (BHPS). We consider two branches of the literature. One suggests that “atypical” contractual conditions have a significant impact on health while the other suggests that health is damaged by adverse working conditions. The main objective of our paper is to combine the two branches of the literature to assess the distinct effects of contractual and working conditions on health. The results suggest that both sets of conditions have some influence on health and psychological well-being of employees

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

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

Inequality and polarisation in health systems’ responsiveness: a cross-country analysis

The World Health Report 2000 proposed three fundamental goals for health systems encompassing population health, health care finance and health systems responsiveness. The goals incorporate both an efficiency and equity dimension. While inequalities in population health and health care finance have motivated two important strands of research, inequalities in responsiveness have received less attention in health economics. This paper examines inequality and polarisation in responsiveness, bridging this gap in the literature and contributing towards an integrated analysis of health systems performance. It uses data from the World Health Survey to measure and compare inequalities in responsiveness across 25 European countries. In order to respect the inherently ordinal nature of the responsiveness data, median-based measures of inequality and polarisation are employed. The results suggest that, in the face of wide differences in the health systems analysed, there exists large variability in inequality in responsiveness across countries

The effects of health shocks on risk preferences : Do personality traits matter?

Older individuals hold a disproportionate amount of total wealth, and are particularly vulnerable to shocks to health. Accordingly, there is a interest in understanding the extent to which health detriments influence financial choices and portfolio holdings within this group of society. A separate strand of literature has recently focused on the role of non-cognitive skills, and in particular personality traits, in shaping attitudes towards risk. We combine these literatures to explore the extent to which unanticipated shocks to health display heterogeneous impacts on preferences towards financial risk via portfolio investments and stock market participation. We find that health shocks have a negative effect on the level of risk at the household level when men, but not women, experience the shock. Moreover, there appears to be heterogeneity in the response by personality trait. Households where men display dominant traits for neuroticism, extraversion and openness to experience tend to be most affected in investment decisions following a health shock. The household becomes less risk tolerant when the level of neuroticism or openness increases, and more risk tolerant when the level of extroversion of the man increases