Cost-containment in health care: The case of Spain from the eighties up to 1997

The purpose of this paper is to provide an overview of the evolution of health care expenditure in Spain during the period 1980-1997, and henceforth to comment on the cost containment measures put forward to control its growth. The paper is divided into three separate sections. The first offers a brief description of the Spanish Health Care System, with emphasis placed on the issue of expenditure control and health planning targets. The second part outlines a set of cost containment measures that has accompanied the process of extending universal health care coverage which occurred during the mentioned period and which has helped keep public expenditure under control. Finally, the third part describes some of the more recent proposals for reform of the Spanish Health Care Sector.Cost containment, health care, the spanish NHS, health economics

Life-time redistribution effects of the Spanish public pension system

The paper analyses the inter and intragenerational redistribution effects of the public pensions system in Spain. This is achieved by first comparing the expected present value of life-time income transfers (PVT) and internal rates of return (IRR) of different population cohorts. Secondly, we study the intragenerational aspects of the Spanish public pensions by calculating PVTs the IRRs for workers of different categories, grouped by earnings, gender and marital status. The results obtained show the nature of the important intergenerational effects of the Social Security System in Spain. The oldest 1935 cohort clearly benefits in relation to the youngest 1965 cohort. This is basically due to the gap between current wages and the contribution bases established in the 60s and 70s in Spain during the early stages of the Social Security System, and to the worsening shortfall in Social Security funding, combined with the longer of life expectancy. In addition, intragenerational effects exist by income levels. For contributors who pay between the minimum and the maximum allowable contribution bases, net transfers and rates of return are higher in actuarial terms for high income contributors. The social security `dealï is again more profitable for high income individuals since they contribute at the maximum basis, with respect to low income contributors at the minimum basis. This is due to the late entry and a higher survival rate for high income contributors. The system tends to favour women, given that they generally live longer than men and this factor is only partially offset by their lower wages. Married males, given the fact that they have longer life expectancy and leave a pension to their spouse, obtain higher present net transfers too than do single contributors. We close the paper with some comments on the slight impact and moderate effects of proposals for Social Security reform and on how these may change the previously observed redistribution effects.Social Security in Spain, Life-time contributions and retirement

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

A multilevel analysis on the determinants of regional health care expenditure. A note

We apply a multilevel hierarchical model to explore whether an aggregation fallacy exists in estimating the income elasticity of health expenditure by ignoring the regional composition of national health expenditure figures. We use data for 110 regions in eight OECD countries in 1997: Australia, Canada, France, Germany, Italy, Spain, Sweden and United Kingdom. In doing this we have tried to identify two sources of random variation: within countries and between-countries. Our results show that: 1- Variability between countries amounts to (SD) 0.5433, and just 13% of that can be attributed to income elasticity and the remaining 87% to autonomous health expenditure; 2- Within countries, variability amounts to (SD) 1.0249; and 3- The intra-class correlation is 0.5300. We conclude that we have to take into account the degree of fiscal decentralisation within countries in estimating income elasticity of health expenditure. Two reasons lie behind this: a) where there is decentralisation to the regions, policies aimed at emulating diversity tend to increase national health care expenditure; and b) without fiscal decentralisation, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure.OECD health expenditure, fiscal federalism, multilevel hierarchical models

The drift of public spending towards the elderly: A generational analysis of the trend of public policies in Spain

The tendency for public welfare spending to be increasingly aimed at the elderly has been pointed out for the US and other developed countries. While population ageing is a common trend, it is not obvious why the shift in spending exceeds the trend in ageing, or why per capita spending on the elderly increases. We show that this is the case in Spain, identify the losers from this development, discuss the policies that underlie this trend, and propose adjustments based on Musgrave’s fixed proportions rule as an inter-generationally fair distribution.Intergenerational equity, Musgrave’s rule, Spanish social policy and ageing

Finance versus costs for teaching hospitals in Spain

In this paper we analyse the observed systematic differences in costs for teaching hospitals (THhenceforth) in Spain. Concern has been voiced regarding the existence of a bias in the financing of TH’s has been raised once prospective budgets are in the arena for hospital finance, and claims for adjusting to take into account the ‘legitimate’ extra costs of teaching on hospital expenditure are well grounded. We focus on the estimation of the impact of teaching status on average cost. We used a version of a multiproduct hospital cost function taking into account some relevant factors from which to derive the observed differences. We assume that the relationship between the explanatory and the dependent variables follows a flexible form for each of the explanatory variables. We also model the underlying covariance structure of the data. We assumed two qualitatively different sources of variation: random effects and serial correlation. Random variation refers to both general level variation (through the random intercept) and the variation specifically related to teaching status. We postulate that the impact of the random effects is predominant over the impact of the serial correlation effects. The model is estimated by restricted maximum likelihood. Our results show that costs are 9% higher (15% in the case of median costs) in teaching than in non-teaching hospitals. That is, teaching status legitimately explains no more than half of the observed difference in actual costs. The impact on costs of the teaching factor depends on the number of residents, with an increase of 51.11% per resident for hospitals with fewer than 204 residents (third quartile of the number of residents) and 41.84% for hospitals with more than 204 residents. In addition, the estimated dispersion is higher among teaching hospitals. As a result, due to the considerable observed heterogeneity, results should be interpreted with caution. From a policy making point of view, we conclude that since a higher relative burden for medical training is under public hospital command, an explicit adjustment to the extra costs that the teaching factor imposes on hospital finance is needed, before hospital competition for inpatient services takes place.Cost functions, semi-parametric estimation, regression analysis, teaching hospitals, prospective payments

Dynamical Coulomb blockade of thermal transport

The role of energy exchange between a quantum system and its environment is investigated from the perspective of the Onsager conductance matrix. We consider the thermoelectric linear transport of an interacting quantum dot coupled to two terminals under the influence of an electrical potential and a thermal bias. We implement in our model the effect of coupling to electromagnetic environmental modes created by nearby electrons within the P(E)-theory of dynamical Coulomb blockade. Our findings relate the lack of some symmetries among the Onsager matrix coefficients with an enhancement of the efficiency at maximum power and the occurrence of the heat rectification phenomenon.Comment: 9 pages, 7 figure

A chiral Maxwell Demon

We investigate the role of chirality on the performance of a Maxwell demon implemented in a quantum Hall bar with a localized impurity. Within a stochastic thermodynamics description we investigate the ability of such a demon to drive a current against a bias. We show that the ability of the demon to perform is directly related to its ability to extract information from the system. The key features of the proposed Maxwell demon are the topological properties of the quantum Hall system. The asymmetry of the electronic interactions felt at the localized state when the magnetic field is reversed joined to the fact that we consider energy dependent (and asymmetric) tunneling barriers that connect such state with the Hall edge modes allow the demon to properly work.Comment: 5 pages, 5 figure

The effects of poor financial information systems on the long term sustainability of local public services. Empirical evidence from the Catalan Municipalities

In this paper we describe the existence of financial illusion in public accounting and we comment on its effects for the future sustainability of local public services. We relate these features to the lack of incentives amongst public managers for improving the financial reporting and thus management of public assets. Financial illusion pays off for politicians and managers since it allows for larger public expenditure increases and managerial slack, these being arguments in their utility functions. This preference is strengthen by the short time perspective of politically appointed public managers. Both factors run against public accountability. This hypothesis is tested for Spain by using an unique sample. We take data from around forty Catalan local authorities with population above 20,000 for the financial years 1993-98. We build this data basis from the Catalan Auditing Office Reports in a way that it can be linked to some other local social and economic variables in order to test our assumptions. The results confirm that there is a statistical relationship between the financial illusion index (FI as constructed in the paper) and higher current expenditure. This reflects on important overruns and increases of the delay in paying suppliers, as well as on a higher difficulties to face capital finance. Mechanisms for FI creation have to do among other factors, with delays in paying suppliers (and thereafter higher future financial costs per unit of service), no adequate provision for bad debts and lack of appropriate capital funding either for reposition or for new equipments. For this, it is crucial to monitor the way in which capital transfers are accounted in local public sheet balances. As a result, for most of the Municipalities we analyse, the funds for guaranteeing continuity and sustainability of public services provision are today at risk. Given managerial incentives at present in public institutions, we conclude that public regulation recently enforced for assuring better information systems in local public management may not be enough to change the current state of affairs.Public management, financial information systems, financial illusion, and Spanish local authorities

Una visión de futuro de las políticas de salud

Data aproximada entre els anys 1998 a 2000Primer pla d'un bloc d'habitatges al carrer Baluard, 6 amb el carrer Monjo, 5. El seu nivell de catalogació és el C