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.health care demand; private provision; waiting times; cost-sharing; equity, agent-based model

Measuring Hospital Efficiency through Data Envelopment Analysis when Policy-makers’ Preferences Matter. An Application to a sample of Italian NHS hospitals

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.Hospital performance, Technical efficiency, Data envelopment analysis, NationalHealth Service

Investment decisions in hospital technology when physicians are devoted workers

Hospital Technology, Devoted worker, Quality, Irreversible investment, Real options.

Quality and Investment Decisions in Hospital Care when Physicians are Devoted Workers

This paper analyses the decision to invest in quality by a hospital in an environment where doctors are devoted workers, i.e. they care for specific aspects of the output they produce. We assume that quality is the result of both an investment in new technology and the effort of the medical staff. Hospital services are paid on the basis of their marginal cost of production while the number of patients treated depends on a purchasing rule which discriminates for the level and timing of the investment. We show that the presence of devoted doctors affects the trade-off between investment and the purchasing rule so that for the hospital it is not always optimal to anticipate the investment decision.Hospital technology, Devoted worker, Quality, Irreversible investment, Real options

Quality and Investment Decisions in Hospital Care when Physicians are Devoted Workers

This paper analyses the decision to invest in quality by a hospital in an environment where doctors are devoted workers, i.e. they care for specific aspects of the output they produce. We assume that quality is the result of both an investment in new technology and the effort of the medical staff. Hospital services are paid on the basis of their marginal cost of production while the number of patients treated depends on a purchasing rule which discriminates for the level and timing of the investment. We show that the presence of devoted doctors affects the trade-off between investment and the purchasing rule so that for the hospital it is not always optimal to anticipate the investment decision

Getting to the Roots of Long-Term Care Needs: A Regression Tree Analysis

This paper investigates the effects of individual and environmental determinants on physical and cognitive impairment of Europeans aged 50 and older using data drawn from the Survey of Health Aging and Retirement in Europe (SHARE). The aim is to understand the different paths that need-related determinants of long-term care might take across individuals. As dependent variables, we consider several measures of physical and cognitive disability which are regressed on a list of covariates which includes biological, health, behavioural, socio-demographic and early-life conditions of individuals. We adopt a methodology that combines the structure of random effects models for longitudinal data with the flexibility of a tree regression method. We show the existence of clusters in the main determinants of functional decline (physical and cognitive). Our findings are in line with the existing literature, but, at the same time, we further characterize previous evidence: 1) cognitive impairment, measured by the results of a memory test, strongly depends on educational attainments, age and respondents’ country of residence; 2) physical impairment, measured through the loss of handgrip strength, basic and instrumental activities of daily living (ADLs, IADLs) and mobility, strongly depends on health and behavioural factors

Libertarian Paternalism and Health Care Policy: A Deliberative Proposal

Cass Sunstein and Richard Thaler have been arguing for what they named libertarian paternalism (henceforth LP). Their proposal generated extensive debate as to how and whether LP might lead down a full-blown paternalistic slippery slope. LP has the indubitable merit of having connected the best of the empirical psychological and sociological evidence to public and private policy making. It is unclear, though, to what extent the implementation of policies so constructed could enhance the capability for the exercise of an autonomous citizenship. Sunstein and Thaler submit it that in most of the cases in which one is confronted with a set of choices, some default option must be picked out. In those cases whoever devises the features of the set of options ought to rank them according to the moral principle of non-maleficence and possibly to that of beneficence. In this paper we argue that LP can be better implemented if there is a preliminary deliberative debate among the stakeholders that elicits their preferences, and makes it possible to rationally defend them

Healthier lifestyles after retirement in Europe? Evidence from SHARE

This paper investigates changes in health behaviours upon retirement, using data drawn from the Survey of Health Aging and Retirement in Europe (SHARE). By exploiting changes in eligibility rules for early and normal retirement, we identify the causal effect of retiring from work on smoking, alcohol drinking, engagement in physical activity and visits to the general practitioner or specialist. We provide evidence about heterogeneous effects related to gender, education, net wealth, early-life conditions and job characteristics. Results show that changes in health behaviours occur upon retirement and may be a key mechanism through which the latter affects health. We find heterogenous effects related especially to gender, education and job characteristics

Valutazione dei progetti in un quadro federale: aspetti dell'esperienza statunitense

Il lavoro \ue8 articolato in cinque paragrafi. Nel primo si fornisce un quadro sintetico sulla spesa pubblica in conto capitale negli Stati Uniti. Nel secondo paragrafo si procede a esaminare i criteri di valutazione dei progetti di investimento pubblico negli USA, illustrando le attivit\ue0 di valutazione svolte da Office of Management and Budget (OMB), Congressional Budget Office (CBO) e General Accounting Office (GAO). Nel terzo paragrafo si illustra la metodologia di analisi dei progetti di sviluppo delle risorse idriche prediaposta dal Water Resource Council (WRC). Nel quarto paragrafo si espongono i criteri secondo cui l'Environme ntal Protection Agency (EPA) procede a valutare costi e benefici delle diverse misure di regolamentazione ambientale. Infine, il quinto paragrafo analizza le procedure di valutazione degli investimenti infrastrutturali realizzati a livello locale

Dalla teoria dei beni pubblici locali al federalismo funzionale

This paper illustrates some of the main results within local public finance, focusing on the relationships between local public goods (LPGs), club goods and fiscal federalism theories. The paper also considers competitive federalism and functional federalism, two models recently proposed in order to overcome the limits of traditional theories on LPGs and fiscal federalism. The analysis especially concentrates on functional federalism. Initially, section 2 gives a broad definition of local public goods (LPGs), pointing out the analogy between this category of collective goods and club goods. Section 3 analyzes the main contents of competitive models of LPGs supply developed by Tiebout, Buchanan and Berglas. Section 4 underlines the limits of these models and shows how many factors give rise to a LPGs market characterized by a restricted number of local jurisdictions. In section 5, after illustrating the fiscal equivalence principle, the fundamentals and the conceptual limits of traditional normative theory of fiscal federalism are exposed; moreover, it is shown how a model of competitive federalism could overcome the drawbacks of traditional normative approach, by resorting to some properties of the competitive models of LPGs allocation. Section 6 analyzes the theoretical foundations and some examples of the model of functional federalism; given the existing framework of local governments, functional federalism can minimize the shifting from the fiscal equivalence principle, being based on the formation - through cooperative agreements between individuals or local communities - of a system of single or multi-function jurisdictions each corresponding to a optimally sized club providing a LPG or a set of LPGs. Finally, section 7 suggests some directions for future research