Developments in health economics and public policy最新文献

We examine the implications of the EU directive on the application of patients' rights in cross-border healthcare on the German sickness fund system. Since Germany implemented most requirements of the directive already in 2004, we first review Germany's experience with EU cross-border healthcare. We then focus on the possible effects of increased EU cross-border healthcare. While this gives patients more choice, the German sickness fund system faces a number of challenges. EU cross-border care may undermine efforts to keep healthcare expenditure under control. Cross-border care can also increase inequality of access. Furthermore, promoting cross-border care can be a means for sickness funds to attract good risks. We discuss these challenges and point out possible policy responses.

According to the economic theory of federalism (Oates 1999), a decentralized decision to collectively fund and supply the quantity and quality of public services will increase economic welfare as long as three conditions are fulfilled: preferences and production costs of the different local constituencies are heterogeneous; local governments are better informed than the central agency because of their proximity to the citizens; and the competition between local governments exerts a significant impact on the performance of the local administration and on the ability of public agencies to implement policy innovation. Federalism also presents some negative aspects, including the opportunity costs of decentralization, which materialize in terms of unexploited economies of scale; the emergence of spillover effects among jurisdictions; and the risk of cost-shifting exercises from one layer of the government to the other. Finally, competition between fiscal regimes can affect the level of equity. The literature considers fiscal federalism as a mechanism for controlling the size of the public sector and for constraining the development of redistributive measures. The present paper reviews the impact that federalism has on the efficiency, equity, and cost containment of the healthcare system in Switzerland, a country with a strongly decentralized political system that is based on federalism and the institutions of direct democracy, a liberal economic culture, and a well-developed tradition of mutualism and social security (generous social expenditure and welfare system). By analyzing the empirical evidence available for Switzerland, we expect to draw some general policy lessons that might also be useful for other countries.

Welfare systems are designed on geographical and membership boundaries. In terms of access to health care this implies that, as a general rule, only individuals residing in their national territory can obtain health care from providers located there. However, in the past few years medical tourism has grown at an explosive pace throughout the world and in Europe. Each year in fact a small, but significant number of European citizens seek medical treatment that is financed by their public insurer in another EU country. From an economic point of view, it is important to distinguish between the two following sources of patients' mobility: a regulated mobility, where the third payer decides to send patients abroad and patients' choice, where the patient himself decides to seek care abroad. In this article we show how the combined effect of restrictions to the use of health care, transfer prices, and mobility rules determine social welfare and its allocation between Regions. The results are quite interesting: if the price set for these patients is equal to the marginal cost of the more efficient Region, patients' mobility should be preferred to patients' choice. On the other hand, if the price is equal to the marginal cost of the less efficient Region, patient choice should be preferred. The other interesting result is a possible trade off between a static model where each Region chooses its level of cost/effectiveness and a more long-term situation, where patient mobility determines a common level for this parameter.

This chapter examines patient mobility across Italian regions using data on hospital discharges that occurred in 2008. The econometric analysis is based on Origin-Destination (OD) flow data. Since patient mobility is a crucial phenomenon in contexts of hospital competition based on quality and driven by patient choice, as is the case in Italy, it is crucial to understand its determinants. What makes the Italian case more interesting is the decentralization of the National Health Service that yields large regional variation in patient flows in favor of Centre-Northern regions, which typically are 'net exporters' of hospital treatments. We present results from gravity models estimated using count data estimators, for total and specific types of flows (ordinary admissions, surgical DRGs and medical DRGs). We model cross-section dependence by specifically including features other than geographical distance for OD pairs, such as past migration flows and the share of surgical DRGs. Most of the explanatory variables exhibit the expected effect, with distance and GDP per capita at origin showing a negative impact on patient outflows. Past migrations and indicators of performance at destination are effective determinants of patient mobility. Moreover, we find evidence of regional externalities due to spatial proximity effects at both origin and destination.

Whenever processes are reconfigured or new products are designed the needs and preferences of patients and consumers have to be considered. Although at times neglected, this becomes more and more relevant in health care settings: Which modes of health care delivery will be accepted? What are the patients' priorities and what is the willingness to pay? To which degree are patients mobile and for which kind of services are they willing to travel? Preferences, however, are difficult to measure, as they are latent constructs. This becomes even more difficult, when no past choices can be analyzed either as the service or the product is yet to be developed or as in the past there has not been free choice for patients. In such cases, preferences cannot be surveyed directly. Asking individuals openly for their attitudes towards certain services and products, the results are likely biased as individuals are not confronted with budget constraints and trade-offs. For this reason, discrete choice experiments (DCEs) are frequently used to elicit patient preferences. This approach confronts patients with hypothetical scenarios of which only one can be chosen. Over the past few years, this tool to reveal patients' preferences for health care has become very popular in health economics. This contribution aims at introducing the principles of DCEs, highlighting the underlying theory and giving practical guidance for conducting a discrete choice experiment in health economics. Thereby we focus on three major fields of patient demand: designing health insurance, assessing patient utility of new pharmaceuticals and analyzing provider choice. By having a closer look at selected international studies, we discuss the application of this technique for the analysis of the supply and the demand of health care as well as the implications for assessing patient mobility across different health care systems.

Policymakers are increasingly designing policies that encourage patient choice and therefore mobility across providers. Since prices are regulated (fixed) in most countries, providers need to compete on quality to attract patients. This chapter reviews the current theoretical and empirical literature on patient choice and quality competition in health markets. The theoretical literature identifies key factors affecting incentives to provide quality. These include: altruistic motives, cost structure, number of providers, demand responsiveness, GP gatekeeping, degree of specialization, profit constraints and soft budgets. We also review the theoretical literature on choice across different countries (e.g. within the EU) or regions within the same countries. The chapter reviews selected empirical studies that investigate whether demand responds to quality and waiting times, the role of patient's mobility and the effect of competition on quality.

The diffusion of the welfare state has produced a widespread involvement of the public sector in financing the production of private goods for paternalistic reasons. In this chapter we model the production of health care as a merit impure local public good whose consumption is subsidized and whose access is free, but not unlimited. The impure local public good aspect means that the production of health care spreads its benefits beyond the geographical boundaries of the Region where it is produced. Finally, we include the (optional) provision of an equalization grant that allows reduction of fiscal imbalance among Regions. In this framework we study the possible effects of cross border provision of health care. We assume that information is complete and symmetric and that there is no comparative advantage in local provision. In this context devolution is always suboptimal for the whole community: the lack of coordination means that the impure public good is under-provided. However, more efficient Regions may be better off because of the impure public good nature of health care.

The chapter explains how health professional mobility impacts on the resources and capacity available within a health system, and how this affects service delivery and access. The contrasting experiences of destination countries, which receive foreign inflows of health professionals, and of source countries, which loose workforce due to outflows, are illustrated with country examples. The evidence opens the debate on how EU countries compete for health workforce, what this means for resource-strained, crisis-hit Member States, and whether there is any room for intra-European solidarity. The nexus between patient mobility and health professional mobility is moreover highlighted. This take on free mobility in the EU has received little attention, and while evidence is scarce, it calls for careful analysis when considering the possible effects of free movement on access to care in national health systems. The chapter reformulates the question on 'who wins' and 'who looses' from freedom of movement in the EU to turn our attention away from those who go abroad for care and instead focus on those who stay at home.

The chapter studies hospital competition in a spatially differentiated market in which patient demand reflects the quality/distance mix that maximizes their utility. Treatment is free at the point of use and patients freely choose the provider which best fits their expectations. Hospitals might have asymmetric objectives and costs, however they are reimbursed using a uniform prospective payment. The chapter provides different equilibrium outcomes, under perfect and asymmetric information. The results show that asymmetric costs, in the case where hospitals are profit maximizers, allow for a social welfare and quality improvement. On the other hand, the presence of a publicly managed hospital which pursues the objective of quality maximization is able to ensure a higher level of quality, patient surplus and welfare. However, the extent of this outcome might be considerably reduced when high levels of public hospital inefficiency are detectable. Finally, the negative consequences caused by the presence of asymmetric information are highlighted in the different scenarios of ownership/objectives and costs. The setting adopted in the model aims at describing the up-coming European market for secondary health care, focusing on hospital behavior and it is intended to help the policy-maker in understanding real world dynamics.