Guillem López-Casasnovas

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.

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

Health care in most countries is a rather “local good” for which the fiscal decentralization theory applies and heterogeneity is the result. In order to address the issue of multijurisdictional health care in estimating income elasticity, we constructed a unique sample using data for 110 regions in eight Organisation for Economic Co-operation and Development (OECD) countries in 1997. We estimated this sample data with a multilevel hierarchical model. In doing this, we tried to identify two sources of random variation: within- and between-country variation. The basic purpose was to find out whether the different relationships between health care spending and the explanatory variables are country specific. We concluded that to take into account the degree of fiscal decentralization within countries in estimating income elasticity of health expenditure proves to be important. Two plausible reasons lie behind this: (a) where there is decentralization to the regions, policies aimed at emulating diversity tend to increase national health care expenditure and (b) without fiscal decentralization, central monitoring of finance tends to reduce regional diversity and therefore decrease national health expenditure. The results of our estimation do seem to validate both these points.

A conditional model for estimating the increase in suicides associated with the 2008–2010 economic recession in England

Background Although evidence of the effects of the economic crisis on suicides is quite low, a recent article shows that the increase in suicides in England between 2008 and 2010 could be associated with the rise in unemployment. Our study analysed whether this effect was the same for all regions of England, using a conditional model which explicitly allows estimation of regional time trends and the effects of unemployment on suicides at the regional level. Methods Hierarchical mixed models were used to assess both, suicides attributable to the financial crisis and the association between unemployment and suicides. The number and the (age-standardised) rate of suicides, for men and women separately, were the dependent variables. We considered the nine English regions based on the NUTS 2 level. Results There was an (not statistically significant) increase in the number of suicides between 2008 and 2010. The variation in rates was not statistically significant in England as a whole but there were statistically significant increases and decreases in some regions. Statistically significant associations between unemployment and suicides were only found at regional level. For men, statistically significant unemployment rates were positively associated with age-standardised suicide rates in the South West (0.384), North West (0.260) and North East (0.136), and negatively associated in the East of England (−0.444), East Midlands (−0.236) and London (−0.168). Conclusions The study provides evidence that, even with statistically significant associations, finding variability, but no clear pattern, between trends and associations and/or numbers and rates might in fact suggest relatively spurious relationships; this is a result of not controlling for confounders.

The Socioeconomic Determinants of Health: Economic Growth and Health in the OECD Countries during the Last Three Decades

In times of economic crisis, most countries face the dual challenge of fighting unemployment while restraining social expenditures and closing budget deficits. The spending cuts and lack of employment affect a large number of decisions that have a direct or indirect impact on health. This impact is likely to be unevenly distributed among different groups within the population, and therefore not only health levels may be at risk, but also their distribution. The main purpose of this paper is to explore links between unemployment, economic growth, inequality, and health. We regress a measure of health, the Health Human Development Index (HHDI), against a set of explanatory variables accounting for the countries’ economic performance (GDP growth, unemployment, and income inequality), and some institutional factors related to welfare spending and the nature of the health systems for the past three decades. In addition, we explore the causes for different results obtained using an inequality-adjusted HHDI, vs. the unadjusted HHDI. We describe a panel data model, estimated by random effects, for 32 countries from 1980–2010, in five-year intervals. Our conclusion is that the high economic growth observed in the last decades, together with an increase in the levels of income inequality and/or poverty, explain the observed changes of our index, particularly when this indicator is weighted by health inequality. The remaining institutional variables (the share of social spending, health care expenditure, and the type of health systems) show the expected sign but are not statistically significant. A comment on the methodological pitfalls of the approach completes the analysis.

Health inequalities in the European Union: an empirical analysis of the dynamics of regional differences

In a panel setting, we analyse the speed of (beta) convergence of (cause-specific) mortality and life expectancy at birth in EU countries between 1995 and 2009. Our contribution is threefold. First, in contrast to earlier literature, we allow the convergence rate to vary, and thereby uncover significant differences in the speed of convergence across time and regions. Second, we control for spatial correlations across regions. Third, we estimate convergence among regions, rather than countries, and thereby highlight noteworthy variations within a country. Although we find (beta) convergence on average, we also identify significant differences in the catching-up process across both time and regions. Moreover, we use the coefficient of variation to measure the dynamics of dispersion levels of mortality and life expectancy (sigma convergence) and, surprisingly, find no reduction, on average, in dispersion levels. Consequently, if the reduction of dispersion is the ultimate measure of convergence, then, to the best of our knowledge, our study is the first that shows a lack of convergence in health across EU regions.

Economic considerations regarding pharmaceutical expenditure in Spain and its financing

This book provides a complete approach to the economics of financing medicines and policy implications for the efficiency and equity of health systems. In all health systems with majority public financing, pharmaceutical reimbursement is one of the key factors in policies of change and transformation of health services in order to face the future with guarantees of financial sustainability.

A vueltas con el aseguramiento sanitario privado

Probablemente los temas del aseguramiento sanitario privado son los peor comprendidos y analizados en la economia de la salud de nuestro pais. Estamos tan abocados a lo que tenemos que resulta dificil recuperar perspectiva para analizar lo que podria ser y no es. No en vano se suelen entender poco las implicaciones del teorema de Rotschild-Stiglitz sobre la superioridad paretiana de un sistema de aseguramiento publico. Se ignora a menudo que el acuerdo unanime (por tanto, estructural, normativo, sin dependencia paretiana potencial o compensatoria, sin necesidad de argumentos ideologicos coyunturales, etc.) a favor de una prima unica comunitaria, un pool basico de contingencias obligatoriamente protegido, se fundamenta precisamente en la necesidad, y no ausencia, de un aseguramiento complementario privado. Sin este no hay pareto superioridad, ya que es lo que determina, por encima del seguro obligatorio, el equilibrio separador en el que ambas partes (los buenos y malos riesgos poblacionales) mejoran su bienestar a la vez. El alcance del componente obligatorio, depende del peso de la poblacion de riesgos altos en la poblacion total, lo que suele determinar una cobertura publica minimo basica.

Has the economic crisis widened the intraurban socioeconomic inequalities in mortality? The case of Barcelona, Spain

Background There is considerable evidence demonstrating socioeconomic inequalities in mortality, some of which focuses on intraurban inequalities. However, all the studies assume that the spatial variation of inequalities is stable over the time. We challenge this assumption and propose two hypotheses: (i) have spatial variations in socioeconomic inequalities in mortality at an intraurban level changed over time? and (ii) as a result of the economic crisis, has the gap between such disparities widened? In this paper, our objective is to assess the effect of the economic recession on the spatio-temporal variation of socioeconomic inequalities in mortality in Barcelona (Catalonia, Spain). Methods We used a spatio-temporal ecological design to analyse mortality inequalities at small area level in Barcelona. Mortality data and socioeconomic indicators correspond to the years 2005 and 2008–2011. We specified spatio-temporal ecological mixed regressions for both men and women using two indicators, neighbourhood and year. We allowed the coefficients of the socioeconomic variables to differ according to the levels and explicitly took into account spatio-temporal adjustment. Results For men and women both absolute and, above all, relative risks for mortality have increased since 2009. In relative terms, this means that the risk of dying has increased much more in the most economically deprived neighbourhoods than in the more affluent ones. Conclusions Although the geographical pattern in relative risks for mortality in neighbourhoods in Barcelona remained very stable between 2005 and 2011, socioeconomic inequalities in mortality at an intraurban level have surged since 2009.

La financiación autonómica de la sanidad. Algunas afirmaciones, valoraciones y constataciones

Si en algun tema resulta facil comprobar la disociacion entre teoria y hechos, este es el de la financiacion autonomica de la sanidad. Como esta es una cuestion que forma parte de mi agenda investigadora, y de la que creo conocer algo sus «tripas», me permitire en esta breve nota, a la que me invitan los editores de Gaceta Sanitaria, ser contundente en algunas afirmaciones. Como ello a veces puede confundirse con ignorancia y simplismo, solicito del amable lector el in dubio pro reo, que avalan mis multiples trabajos publicados sobre el tema (una revision general de dicha literatura puede encontrarse en Lopez-Casasnovas: «La financiacion del sistema sanitario espanol y su incidencia en el gasto: perspectivas macro, territorial y funcional», AES, 2000).

The association between exposure to environmental factors and the occurrence of attention-deficit/hyperactivity disorder (ADHD). A population-based retrospective cohort study

Background: A number of factors contribute to attention deficit hyperactivity disorder (ADHD) and although they are not fully known, the occurrence of ADHD seems to be a consequence of an interaction between multiple genetic and environmental factors. However, apart from pesticides, the evidence is inadequate and inconsistent as it differs not only in the population and time period analysed, but also in the type of study, the control of the confounding variables and the statistical methods used. In the latter case, the studies also differ in the adjustment of spatial and temporal variability. Our objective here, is to provide evidence on an association between environmental factors and ADHD. Methods: In our study, we used a population‐based retrospective cohort in which we matched cases and controls (children free of the disease) by sex and year of birth (n = 5193, 78.9% boys). The cases were children born between 1998 and 2012 and diagnosed with ADHD (n = 116). To evaluate whether there was a geographical pattern in the incidence of ADHD, we first represented the smoothed standardized incidence rates on a map of the region being studied. We then estimated the probability of being a case by using a generalized liner mixed model with a binomial link. As explanatory variables of interest, we included the following environmental variables: distance to agricultural areas, distance to roads (stratified into three categories according to traffic density and intensity), distance to petrol stations, distance to industrial estates, and land use. We control for both observed (individual and family specific variables and deprivation index) and unobserved confounders (in particular, individual and familial heterogeneity). In addition, we adjusted for spatial extra variability. Results: We found a north‐south pattern containing two clusters (one in the centre of the study region and another in the south) in relation to the risk of developing ADHD. The results from the multivariate model suggest that these clusters could be related to some of the environmental variables. Specifically, living within 100 m from an agricultural area or a residential street and/or living fewer than 300 m from a motorway, dual carriageway or one of the industrial estates analysed was associated (statistically significant) with an increased risk of ADHD. Conclusion: Our results indicate that some environmental factors could be associated with ADHD occurring, particularly those associated with exposure to pesticides, organochlorine compounds and air pollutants because of traffic. HighlightsWe found a certain north‐south pattern for the risk of occurrence of ADHD.These clusters could be related to some of the environmental variables.In particular, an increased risk of occurrence of ADHD was found.Living less than 100 m from an agricultural area or a residential Street.Living less than 300 m from a motorway/dual carriageway or an industrial estate.