The simple economics of risk-sharing agreements between the NHS and the pharmaceutical industry

The Janssen-Cilag proposal for a risk-sharing agreement regarding bortezomib received a welcome signal from NICE. The Office of Fair Trading report included risk-sharing agreements as an available tool for the National Health Service. Nonetheless, recent discussions have somewhat neglected the economic fundamentals underlying risk-sharing agreements. We argue here that risk-sharing agreements, although attractive due to the principle of paying by results, also entail risks. Too many patients may be put under treatment even with a low success probability. Prices are likely to be adjusted upward, in anticipation of future risk-sharing agreements between the pharmaceutical company and the third-party payer. An available instrument is a verification cost per patient treated, which allows obtaining the first-best allocation of patients to the new treatment, under the risk sharing agreement. Overall, the welfare effects of risk-sharing agreements are ambiguous, and care must be taken with their use.risk sharing agreements; pharmaceutical prices

An economic theory of church strictness

This paper makes several contributions to the growing literature on the economics of religion. First, we explicitly introduce spatial- location models into the economics of religion. Second, we offer a new explanation for the observed tendency of state (monopoly) churches to locate toward the "low-tension" end of the "strictness continuum" (in a one-dimensional product space): This result is obtained through the conjunction of "benevolent preferences" (denominations care about the aggregate utility of members) and asymmetric costs of going to a more or less strict church than one prefers. We also derive implications regarding the relationship between religious strictness and membership. The driving forces of our analysis, religious market interactions and asymmetric costs of membership, high-light new explanations for some well-established stylized facts. The analysis opens the way to new empirical tests, aimed at confronting the implications of our model against more traditional explanations.Location theory, economics of religion

Economies of scale and scope in the provision of diagnostic techniques and therapeutic services in Portuguese hospitals

This paper analyses the provision of auxiliary clinical services that are typically carried out within the hospital. We estimate a flexible cost function for the three most important (cost- wise) diagnostic techniques and therapeutic services in Portuguese hospitals: Clinical Pathology, Medical Imaging and Physical Medicine and Rehabilitation. Our objective in carrying out this estimation is the evaluation of economies of scale and scope in the provision of these services. For all services, we find evidence of ray economies of scale and some evidence of economies of scope. These results have important policy implications and can be related to the ongoing discussion of where and how should hospitals provide these services.translog cost function, economies of scale, economies of scope, clinical services, hospitals

Technological adoption in health care

This paper addresses the impact of payment systems on the rate of technology adoption. We present a model where technological shift is driven by demand uncertainty, increased patients’ benefit, financial variables, and the reimbursement system to providers. Two payment systems are studied: cost reimbursement and (two variants of) DRG. According to the system considered, adoption occurs either when patients’ benefits are large enough or when the differential reimbursement across technologies offsets the cost of adoption. Cost reimbursement leads to higher adoption of the new technology if the rate of reimbursement is high relative to the margin of new vs. old technology reimbursement under DRG. Having larger patient benefits favors more adoption under the cost reimbursement payment system, provided that adoption occurs initially under both payment systems. JEL codes: I11, I12, Q33

Hospital production in a national health service: the physician's dilemma

There is a paucity of literature concerning the relation between the resource utilization decisions of the salaried hospital based physician and patient outcomes in a national health service. The purpose of our study is to model and test hospital production where the major decision makers are physicians. We view the output of the hospital as a distribution function over final health states of the patient. Our model contains a utility function for physicians whose arguments include the expected final health status of the patient and a pressure function which reflects the resource allocation and hospital financing policy of the Portuguese Health Ministry. Two sets of first order conditions derived from the theoretical model are estimated within a simultaneous equations framework using data consisting of inpatient discharges for the most frequent non-obstetric DRG during the 1992-1999 time period. We find evidence that budget setting methods and the possession of a third party payer outside of the NHS are important predictors for use of the resource in question. Moreover, we find that use of the resource is important in predicting the final health status of the patient.

Ex-ante Moral Hazard and Primary Prevention, evidence from Portugal

This paper provides evidence on ex-ante moral hazard in Portugal. The issue is addressed in a setting where people buy voluntary private health insurance, on top of existing Government coverage. We identify the main factors that lead people to adopt healthy lifestyles, such as taking up sports and not smoking, which are associated with primary prevention. Moreover, it allows for an inference of the role of risk aversion of individuals in these decisions. We use a GHK recursive simulator of multivariate probit for insurance demand, smoking and sporting decisions, to provide joint estimates taking into consideration potential endogeneity of these decisions. Our results indicate that there is some evidence of ex-ante moral hazard with respect to primary prevention behaviors. Di¤erences in risk aversion across individuals do not seem to play a primary role in explaining distinct life styles.ex-ante moral hazard, prevention, lifestyles

Technological adoption in health care

This paper addresses the impact of payment systems on the rate of technology adoption. We present a model where technological shift is driven by demand uncertainty, increased patients' benefit, financial variables, and the reimbursement system to providers. Two payment systems are studied: cost reimbursement and (two variants of) DRG. According to the system considered, adoption occurs either when patients' benefits are large enough or when the differential reimbursement across technologies offsets the cost of adoption. Cost reimbursement leads to higher adoption of the new technology if the rate of reimbursement is high relative to the margin of new vs. old technology reimbursement under DRG. Having larger patient benefits favors more adoption under the cost reimbursement payment system, provided that adoption occurs initially under both payment systems.Health care, technology adoption, payment systems

Health Care and Health Outcomes of Migrants: Evidence from Portugal

This paper studies the performance of immigrants relative to natives, in terms of their health status, use of health care services, lifestyles, and coverage of health expenditures. We base the analysis on international evidence that identified a healthy immigrant effect, complemented by empirical research on the Portuguese National Health Survey. Furthermore, we assess whether differences in health performance depend on the personal characteristics of the individuals or can be directly associated with their migration experience.Migration, health status, health care, healthy immigrant effect, Portugal

Bargaining and idle public sector capacity in health care

A feature present in countries with a National Health Service is the co-existence of a public and a private sector. Often, the public payer contracts with private providers while holding idle capacity. This is often seen as inefficiency from the management of public facilities. We present here a different rationale for the existence of such idle capacity: the public sector may opt to have idle capacity as a way to gain bargaining power vis-à-vis the private provider, under the assumption of a more efficient private than the public sector.

Negotiation Advantages of Professional Associations in Health Care

In several instances, third-party payers negotiate prices of health care services with providers. We show that a third-party payer may prefer to deal with a professional association than with the sub-set constituted by the more efficient providers, and then apply the same price to all providers. The reason for it is the increase in the bargaining position of providers. The more efficient providers are also the ones with higher profits in the event of negotiation failure. This allows them to ext act a higher surplus from the third-party payer.Professional Associations, Health Care, Negotiation