Technical inefficiency and public capital in US States: A stochastic frontier approach

This paper estimates a translog stochastic frontier production function in the analysis of all 48 contiguous U.S. states in the period 1970-1983, to attempt to measure and explain changes in technical efficiency. The model allows technical inefficiency to vary over time, and inefficiency effects to be a function of a set of explanatory variables in which the level and composition of public capital plays an important role. Results indicated that U.S. state inefficiency levels were significantly and positively correlated with the ratio of public capital to private capital. The proportion of public capital devoted to highways is negatively correlated with technical inefficiency, suggesting that not only the level but also the composition of public capital influenced state efficiency.Public capital productivity, technical efficiency, stochastic frontier approach

The impact of generic reference pricing interventions in the statin market

The objective of this study was to evaluate the intended and unintended impact on pharmaceutical use and sales of three public financing reforms applied to the prescription of statins: a Spanish generic reference pricing (RP) system for lovastatin and simvastatin, and two competing policies introduced by the Andalusian Public Health Service (APHS) for all statins, first a maximum consumer price (MCP) and then a so called quality prescribing incentive for general practitioners (MCP plus PI). This study is designed as an observational, retrospective, interrupted time series analysis with comparison series (APHS and the rest of Spain) of 46 monthly drug use and sales ratios from January 2001 to October 2004 for each active ingredient in the group of statins. RP has been effective at reducing the volume of sales growth of the off-patent statins, yet its overall impact on sales of all statins has been relatively modest. The quantity and volume of sales impact heavily depends on regulatory RP details such as when the system is introduced, how often it is updated, and how the reference price is calculated.Pharmaceutical sales, generic medicines, pharmaceutical reference pricing, statins

Review of the literature on reference pricing

This paper reviews the literature on reference pricing (RP) in pharmaceutical markets. The RP strategy for cost containment of expenditure on drugs is analyzed as part of the procurement mechanism. We review the existing literature and the state-of-the-art regarding RP by focusing on its economic effects. In particular, we consider: (1) the institutional context and problem-related factors which appear to underline the need to implement an RP strategy; i.e., its nature, characteristics and the sort of health care problems commonly addressed; (2) how RP operates in practice; that is, how third party-payers (the insurers/buyers) have established the RP systems existing on the international scene (i.e., information methods, monitoring procedures and legislative provisions); (3) the range of effects resulting from particular RP strategies (including effects on choice of appropriate pharmaceuticals, insurer savings, total drug expenditures, prices of referenced and non-referenced products and dynamic efficiency; (4) the market failures which an RP policy is supposed to address and the main advantages and drawbacks which emerge from an analysis of its effects. Results suggest that RP systems achieve better their postulated goals (1) if cost inflation in pharmaceuticals is due to high prices rather than to the excess of prescription rates, (2) when the larger is the existing difference in prices among equivalent drugs, and (3) more important is the actual market for generics.Reference pricing, pharmaceutical expenditure, generic drugs, drug patents

Market structure and hospital efficiency: Evaluating potential effects of deregulation in a national health service

In this article we examine the potential effect of market structure on hospital technical efficiency as a measure of performance controlled by ownership and regulation. This study is relevant to provide an evaluation of the potential effects of recommended and initiated deregulation policies in order to promote market reforms in the context of a European National Health Service. Our goal was reached through three main empirical stages. Firstly, using patient origin data from hospitals in the region of Catalonia in 1990, we estimated geographic hospital markets through the Elzinga--Hogarty approach, based on patient flows. Then we measured the market level of concentration using the Herfindahl--Hirschman index. Secondly, technical and scale efficiency scores for each hospital was obtained specifying a Data Envelopment Analysis. According to the data nearly two--thirds of the hospitals operate under the production frontier with an average efficiency score of 0.841. Finally, the determinants of the efficiency scores were investigated using a censored regression model. Special attention was paid to test the hypothesis that there is an efficiency improvement in more competitive markets. The results suggest that the number of competitors in the market contributes positively to technical efficiency and there is some evidence that the differences in efficiency scores are attributed to several environmental factors such as ownership, market structure and regulation effects.Geographic markets, market concentration, technical efficiency, data envelopment analysis, censored regression model

Regulatory ambivalence and the limitations of pharmaceutical policy in Spain

Broadly speaking, pharmaceutical policy in Spain has been unable to control either the price or the volume of drugs prescribed. Limited attempts have been made to bring together the regulation of the pharmaceutical market and policies, in pursuit of the desired goals of efficiency and quality. This paper assesses the regulation of the Spanish pharmaceutical market over the last two decades by examining regulation and policy and the available empirical evidence on their appreciable effects, and presents recommendations for policy design. Our findings suggest that policies aiming to improve efficiency and quality have not managed to contain costs, while cost-effectiveness is still overlooked. We argue that future policies should encourage broader participation in the decision-making processes and promote a higher degree of competition, especially from generic drugs.Spain, generic penetration, reference pricing, negative lists, pharmaceutical regulation

Why are some Spanish regions so much more efficient than others?

This article investigates the main sources of heterogeneity in regional efficiency. We estimate a translog stochastic frontier production function in the analysis of Spanish regions in the period 1964-1996, to attempt to measure and explain changes in technical efficiency. Our results confirm that regional inefficiency is significantly and positively correlated with the ratio of public capital to private capital. The proportion of service industries in the private capital, the proportion of public capital devoted to transport infrastructures, the industrial specialization, and spatial spillovers from transport infrastructures in neighbouring regions significantly contributed to improve regional efficiency.Regional efficiency, Regional spillovers, Human capital, Public capital

Measuring and explaining farm inefficiency in a panel data set of mixed farms

This paper aims to estimate a translog stochastic frontier production function in the analysis of a panel of 150 mixed Catalan farms in the period 1989-1993, in order to attempt to measure and explain variation in technical inefficiency scores with a one-stage approach. The model uses gross value added as the output aggregate measure. Total employment, fixed capital, current assets, specific costs and overhead costs are introduced into the model as inputs. Stochastic frontier estimates are compared with those obtained using a linear programming method using a two-stage approach. The specification of the translog stochastic frontier model appears as an appropriate representation of the data, technical change was rejected and the technical inefficiency effects were statistically significant. The mean technical efficiency in the period analyzed was estimated to be 64.0%. Farm inefficiency levels were found significantly at 5% level and positively correlated with the number of economic size units.Technical efficiency, stochastic frontier approach, agricultural economics, frontier productions, farm efficiency

Incentives and pharmaceutical reimbursement reforms in Spain

The aim of this paper is to assess whether cost-containment has been affected by recent pharmaceutical reimbursement reforms that have been introduced in the Spanish health care system over the period 1996-2002, under the conservative Popular Party government. Four main reimbursement policies can be observed in the Spanish pharmaceutical market after 1996, each of them largely unintegrated with the other three. First, a second supplementary negative list of excluded pharmaceutical products was introduced in 1998. Second, a reference pricing system was introduced in December 2000, with annual updating and enlargement. Third, the pharmacies’ payment system has moved from the traditional set margin on the consumer price to a margin that varies according to the consumer price of the product, the generic status of the product, and the volume of sales by pharmacies. And fourth, general agreements between the government and the industry have been reached with cost containment objectives. In the final section of this paper we present an overall assessment of the impact of these pharmaceutical reimbursement policies on the behaviour of the agents in the pharmaceutical market.Spanish health care system, negative list, reference pricing, pharmacy reimbursement, pharmaceutical industry

Health care provider choice in the case of patient-initiated contacts. An extended version of discrete choice of model demand

This paper analyzes the nature of health care provider choice in the case of patient-initiated contacts, with special reference to a National Health Service setting, where monetary prices are zero and general practitioners act as gatekeepers to publicly financed specialized care. We focus our attention on the factors that may explain the continuously increasing use of hospital emergency visits as opposed to other provider alternatives. An extended version of a discrete choice model of demand for patient-initiated contacts is presented, allowing for individual and town residence size differences in perceived quality (preferences) between alternative providers and including travel and waiting time as non-monetary costs. Results of a nested multinomial logit model of provider choice are presented. Individual choice between alternatives considers, in a repeated nested structure, self-care, primary care, hospital and clinic emergency services. Welfare implications and income effects are analyzed by computing compensating variations, and by simulating the effects of user fees by levels of income. Results indicate that compensating variation per visit is higher than the direct marginal cost of emergency visits, and consequently, emergency visits do not appear as an inefficient alternative even for non-urgent conditions.Health care demand, emergency visits, nested multinomial logit, compensating variation, time costs