Gianluca Fiorentini

Incentives In Primary Care and Their Impact on Potentially Avoidable Hospital Admissions

Financial incentives in primary care have been introduced with the purpose of improving appropriateness of care and containing demand. We usually observe pay-for-performance programs, but alternatives, such as pay-for-participation in improvement activities and pay-for-compliance with clinical guidelines, have also been implemented. Here, we assess the influence of different programs that ensure extra payments to GPs for containing avoidable hospitalisations. Our dataset covers patients and GPs of the Italian region Emilia-Romagna for the year 2005. By separating pay-for-performance from pay-for-participation and pay-for-compliance programs, we estimate the impact of different financial incentives on the probability of avoidable hospitalisations. As dependent variable, we consider two different sets of conditions for which timely and effective primary care should be able to limit the need for hospital admission. The first is based on 27 medical diagnostic related groups that Emilia-Romagna identifies as at risk of inappropriateness in primary care, while the second refers to the internationally recognised ambulatory care-sensitive conditions. We show that pay-for-performance schemes may have a significant effect over aggregate indicators of appropriateness, while the effectiveness of pay-for-participation schemes is adequately captured only by taking into account subpopulations affected by specific diseases. Moreover, the same scheme produces different effects on the two sets of indicators used, with performance improvements limited to the target explicitly addressed by the Italian policy maker. This evidence is consistent with the idea that a “tunnel vision” effect may occur when public authorities monitor specific sets of objectives as proxies for more general improvements in the quality of health care delivered.

La disponibilità a pagare per la copertura del rischio di non autosufficienza: analisi econometrica e valutazioni di "policy"

In response to the increasing demand for elderly care, Italy has experienced an intense debate on what should be the most appropriate way to extend coverage for long-term care (LTC). This paper bridges a gap into existing literature by analysing household preferences for LTC coverage in light of an ad hoc survey. We present evidence on household stated willingness to pay (WTP) both for tax financed and private LTC insurance schemes. The distribution of WTP across different socio-economic groups provides insights on the political sustainability of the different institutional solutions. Moreover, estimates of the determinants of demand highlights the importance of income levels and opinion indicators in turning consumer preferences either to public or private schemes. We interpret the different patterns of WTP as evidence of the influence of the redistributive effects inherent to public insurance.

Cartels Run by Criminal Organizations and Market Contestability

Growing empirical evidence shows that firms active in both legal and illegal markets compete to acquire ‘protection’ from criminal organizations which operate as enforcers of collusive agreements among producers. In exchange for this service, criminal organizations receive a share of the profits from the firms which creates a cartel.1 Using a Stiglerian analogy, these criminal organizations act as local regulatory agencies (partially captured by the producers) in competitive markets where the producers would have no strong reason to call for the intervention of a regulatory agency.2 Moreover, in similar conditions collusive agreements among producers would not be sustainable because of the large number of firms involved, and low cost of entry, so that the criminal organizations can be seen as stabilizing factors for collusive agreements. In this respect, Reuter (1987) and Gambetta and Reuter (1995) stress that cartels enforced by criminal organizations usually comprise a large number of firms, something which is counter-intuitive due to the negative relation between profits in the output market and firms active in the market.

Decision Making and Priority Setting: The Evolving Path Towards Universal Health Coverage

Health technology assessment (HTA) is widely viewed as an essential component in good universal health coverage (UHC) decision-making in any country. Various HTA tools and metrics have been developed and refined over the years, including systematic literature reviews (Cochrane), economic modelling, and cost-effectiveness ratios and acceptability curves. However, while the cost-effectiveness ratio is faithfully reported in most full economic evaluations, it is viewed by many as an insufficient basis for reimbursement decisions. Emotional debates about the reimbursement of cancer drugs, orphan drugs, and end-of-life treatments have revealed fundamental disagreements about what should and should not be considered in reimbursement decisions. Part of this disagreement seems related to the equity-efficiency tradeoff, which reflects fundamental differences in priorities. All in all, it is clear that countries aiming to improve UHC policies will have to go beyond the capacity building needed to utilize the available HTA toolbox. Multi-criteria decision analysis (MCDA) offers a more comprehensive tool for reimbursement decisions where different weights of different factors/attributes can give policymakers important insights to consider. Sooner or later, every country will have to develop their own way to carefully combine the results of those tools with their own priorities. In the end, all policymaking is based on a mix of facts and values.

L’analisi economica delle relazioni tra ICT e organizzazioni sanitarie

Starting from the neo-institutional theoretical approach, this article analyses the effects of the growing ICT investments on the boundaries of economic organizations, with particular reference to the dimension of vertical integration. The analysis of the impact of ICT on health organizations reveals very different effects than the shortening of vertical links between various stages of production that is typically observed in other industries. Indeed, the growing trend of health systems to strengthen the institutional and managerial tools to integrate their heterogeneous activities and services in order to provide a more effective support to the prevention, maintenance and recovery of the highest attainable standard of health, enhances the comparative advantages arising from an integrated management of information flows, which further strengthens the advantages of vertically integrated organizational solutions.

Competitive Health Markets and Risk Equalisation in Australia: Lessons Learnt from Other Countries

The aims of this paper are to evaluate the risk equalisation (RE) arrangement in Australia’s private health insurance against practices in other countries with similar arrangements and to propose ways of improving the system to advance economic efficiency and solidarity. Possible regulatory responses to insurance market failures are reviewed based on standard economic arguments. We describe various regulatory strategies used elsewhere to identify essential system features against which the Australian system is compared. Our results reveal that RE is preferred over alternative regulatory strategies such as premium rate restrictions, premium compensation and claims equalisation. Compared with some countries’ practices, the calculated risk factors in Australia should be enhanced with further demographic, social and economic factors and indicators of long-term health issues. Other coveted features include prospective calculation and annual clearing of equalisation payments. Australia currently operates with a crude mechanism for RE in which the scheme incentivises insurers to select on risk rather than focusing on efficiency and equity-promoting actions. System changes should be introduced in a stepwise manner; thus, we propose an incremental reform.

Dealing with minor illnesses: The link between primary care characteristics and Walk-in Centres’ attendances

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments (EDs) to community-based alternatives, has determined a variety of organisational solutions. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a Walk-in Centre (WiC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospitals ED. We examine the link between the utilisation rates of the WiC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the extension of practice opening hours significantly lowers the number of attendances, after controlling for General Practitioners and practices characteristics.

Dealing with Minor Illnesses: The Link between Primary Care Characteristics and First Aid Clinics’ Attendances

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments to community-based alternatives has determined a variety of organisational solutions aimed at reducing the ED overcrowding. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a First-aid clinic (FaC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospital’s ED. We examine the link between the utilisation rates of the FaC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the younger cohorts are heavy users of the FaC and that the extension of practice opening hours significantly lowers the number of attendances, after controlling for GP’s and practice’s characteristics.

Accordi contrattuali tra produttori e finanziatori in un contesto di programmazione sanitaria

During the period 1995-1998, in the Italian NHS, hospital services were provided in a setting characterised by a partial split between purchasers and providers, a DRG-based prospective payment system, and freedom of choice for patients. Managed competition was introduced to reduce prices and improve quality through a better contractual specification of the terms of supply. This paper provides a comparative analysis of the contracts for hospital services between purchasers (AUSLs) and independent public hospitals (AOSPs). The analysis shows that the contractual terms reflected the strong hierarchical control exterted by the Regional Government over the bargaining parties due to the formers responsibility to fund any excess spending. In these highly incomplete contracts, the overall budget was built on a DRG-based mechanism, and financial limits were set on the basis of the historical volumes of production. Due to a lack of productive flexibility, AOSPs systematically violated the budget, and different types of risk-sharing rules were ineffective to that purpose as providers could not be driven out of business. Hence, AUSLs were compelled to purchase hospital services from the local AOSPs at higher prices than those granted by vertically integrated providers. In this context, contracts were used more than to elicit price or quality competition as attempts to control current expenditure and to reduce excess supply. Accordingly, in 1999 most competitive elements of the previous mechanism were replaced by cooperative partnerships between purchasers and producers.

Società a capitale misto nell'offerta di servizi sanitari

The recent reform of the Italian National Health Service brings to the fore some new problems in establishing public-private corporations. This is because producers are introduced in a network where each of them is assigned a monopolistic position. This shifts antitrust concerns from ensuring some freedom of choice for the patients to designing institutions that guarantee some competition to enter the network. To avoid dominant positions, purchasers of health services should examine the comparative advantage of different mechanisms that may provide greater long-terms efficiency and a more favourable allocation of financial risks.