Diogo Cunha Ferreira

Did the corporatization of Portuguese hospitals significantly change their productivity

This paper aims to investigate if the market structure reforms in the Portuguese health system have improved hospital performance and productivity. A robust non-parametric Malmquist index is applied to measure group performance. The significance of the results achieved is examined using a conditional and non-conditional subsampling bootstrapped-based methodology, enhanced by the likelihood cross validation criterion based on the k-nearest neighbors method. The sample contains information about 216 non-corporatized and 176 corporatized Portuguese hospitals for the period 2002–2009. Five models were applied, based on three study dimensions (internment, emergencies and doctor visits). The results show that although corporatized hospitals presented the highest efficiency consistency, they had also the lowest levels of productivity, while the hospitals under the traditional administrative public management system were the ones with the best average performance. However, several best practices were also found in all groups, being the limited companies were often dominated by both non-corporatized and public enterprise entities. Consistent output ranges where all groups present dominance over the others were also identified. It was possible to conclude that the more autonomy the hospital had from the Ministry of Health, the lower was its productivity.

Malmquist and Hicks–Moorsteen Productivity Indexes for Clusters Performance Evaluation

Measuring the performance of clusters characterized by the unbalancedeness and units with no correspondence in other clusters (“uncorrespondencedeness”) has not achieved the desired attention in the literature. Particularly, the operational research has been almost exclusively focused on performance evolution over time, where clusters are generally balanced and the units repeat themselves over these groups. Such analysis has been based on the Malmquist and the Hicks–Moorsteen indexes (MI and HMI), which are solely based on Shephard’s radial distance functions and do not account for all inefficiency sources. Making use of the so-called geometric distance functions (GDFs) and the GDF-based MI, we propose a generalization of the Hicks–Moorsteen index (HMI), based on targets instead of distances to the efficient frontier, allowing the introduction of all inefficiency sources in the productivity model. Moreover, we propose a Monte Carlo-based framework to achieve the pseudo-corresponding units for general cluster performance analysis. This framework is then a generalization of the conventional performance evolution over time. Then, we show that the HMI can be decomposed into economically meaningful indexes and can be rewritten as the geometric mean of the input and the output-oriented MIs. Given these conclusions and our proposed framework, the employment of the HMI to the general clusters analysis is straightforward. Other economically meaningful conclusions are also obtained in this paper.

Should inpatients be adjusted by their complexity and severity for efficiency assessment? Evidence from Portugal

Hospital efficiency analysis depends largely on the model specifications. This study discusses the importance of the case-mix index (CMI) to homogenize the sample of inpatient discharges. It proposes a new index where they are classified by service, since it is usual to have lack of data to compute the CMI and this can influence the credibility of results. Data from the Portuguese national diagnosis-related group (DRG) database was utilized. Three different approaches are developed in this paper, based on locally convex order-m method as well as on translog functions. The first one correlates the efficiency with different inpatients weighting schemes, by using the Nadaraya-Watson method. The second approach compares different frontiers that have been computed using the different weighting schemes. Finally, by using bootstrap, the paper investigates whether the inclusion of severity/ complexity-related variables in the model statistically modifies the results. It has been shown that, under the Portuguese healthcare framework, if the model is environment corrected (which should include epidemiological and main political/ structural health reforms variables), then the severity adjustment of inpatients is pointless. The employment of an inpatient-weighting scheme, such as the CMI, may introduce significant frontier shift, thus its absence is not recommended in productivity evolution analyzes. The CMI shifts the efficiency frontier, but not the relative position of units against it (the last scenario if exogenous variables are present).

Economies of scope in the health sector: The case of Portuguese hospitals

Abstract Background: Economies of scope are defined as the potential cost savings arising from the joint production of two or more outputs rather than their separate production. Given the importance of the health sector for the community, measuring the existence of potential economies of scope contributes to the improvement of this sectors sustainability. Objective(s): To identify economies of scope in Portuguese hospitals using frontier-based methods. Methods: This paper develops (1) a generalized algorithm to obtain locally convex frontiers using the directional order-α (LDOα) frontier method, and (2) a generalized economies-of-scope-based ratio that allows the introduction of any inefficiency source. Data: This paper uses the 2002–2009 dataset for Portuguese hospitals concerning the provision of obstetrics, gynaecology, and paediatrics (OGP), and psychiatric (Psy) services. Results: Considerable economies and diseconomies of scope were found in the Portuguese public hospitals. A considerable dependence on the production line and on the merger status of the hospital was observed. Diseconomies of scope were more likely for larger hospitals, i.e., those with more than 6000 inpatient discharges and/or 7500 medical appointments per year. Conclusions: Even merged hospitals can exploit economies of scope. However, when they become outsized entities, such efforts become more difficult.

Identifying congestion levels, sources and determinants on intensive care units: the Portuguese case

Healthcare systems are facing a resources scarcity so they must be efficiently managed. On the other hand, it is commonly accepted that the higher the consumed resources, the higher the hospital production, although this is not true in practice. Congestion on inputs is an economic concept dealing with such situation and it is defined as the decreasing of outputs due to some resources overuse. This scenario gets worse when inpatients’ high severity requires a strict and effective resources management, as happens in Intensive Care Units (ICU). The present paper employs a set of nonparametric models to evaluate congestion levels, sources and determinants in Portuguese Intensive Care Units. Nonparametric models based on Data Envelopment Analysis are employed to assess both radial and non-radial (in)efficiency levels and sources. The environment adjustment models and bootstrapping are used to correct possible bias, to remove the deterministic nature of nonparametric models and to get a statistical background on results. Considerable inefficiency and congestion levels were identified, as well as the congestion determinants, including the ICU specialty and complexity, the hospital differentiation degree and population demography. Both the costs associated with staff and the length of stay are the main sources of (weak) congestion in ICUs. ICUs management shall make some efforts towards resource allocation to prevent the congestion effect. Those efforts shall, in general, be focused on costs with staff and hospital days, although these congestion sources may vary across hospitals and ICU services, once several congestion determinants were identified.

Doctors, nurses, and the optimal scale size in the Portuguese public hospitals

This study analyses the scale efficiency, optimal scale for hospital clinical staff, and the exogenous dimensions that can be associated with them. They offer useful insights for health policy design, particularly when human resources need to be reallocated across the country due to uneven distributions. Initial data considered a sample of 27 Portuguese general/acute-care public hospitals belonging to the National Health Service, observed between 2013 and 2016. This resulted into a sample of 108 hospitals-year. Data Envelopment Analysis was employed to assess scale efficiency and optimal scale associated with the workforce and at the overall hospital level. Quality and access to health care services adjusted the measures of scale efficiency and optimal size. A multiple regression analysis was carried out to associate optimal scale and scale efficiency to demographics. Optimal scale centred on 274 full-time equivalent (FTE) doctors and 475 FTE nurses. Overall, there is an excess of FTE doctors and FTE nurses, even after potential reallocations. There is an uneven distribution of health workforce, with excess of staff located in urban areas. Hospitals productivity would increase if they reduced their operational scale. Drivers of potential change include population size, childhood mortality rate, birth rate, and purchasing power parity. Health policies are required, not to hire more staff, but rather to promote the reallocation of employees to deprived regions.

The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis

The Portuguese health system concentrates most of its activity in a National Health Service, created in 1979 to promote universal and general access. The National Health Service should ensure equity, efficiency, and quality of all health care delivered services. This study assesses the impact of health care policies between 2002 and 2017, focusing on 3 timeframes: the adoption and adaptation of New Public Management principles to the health care sector (2002 to 2010), the economic and financial crisis period (2011-2015), and the postcrisis recovery period (2016-2017). The current study evaluates the main policy measures in the health sector, presenting their impacts in terms of access, efficiency, accountability, and costs over those 3 economic periods. It was verified that not all the measures implemented by the successive governments obtained the desired outcomes, generating even costs increase, apart from the austerity period in which health expenditure showed a significant reduction because of the financial constraints.