Luca Crivelli

Price regulation of drugs: Lessons from Germany

This paper purports to explain the pricing policy of pharmaceutical companies in Germany prior and after the introduction of reference prices (RP) in 1989. First, the threat of such regulation may have kept prices finite despite a completely insured market. Next, the pricing policies of both the producer of an innovative drug and of a competing generic under RP are predicted. These predictions are then confronted with actual pricing policy for three products in the guise of case studies. Finally, the impact of modified copayment rules on pricing decisions is analyzed.

Leadership and governance in seven developed health systems

This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes.

Regulation, ownership and efficiency in the Swiss nursing home industry

Switzerland is a federal State where policy decisions regarding long-term care regulation are by rights incumbent upon regional and local governments. This situation is in part responsible for the large number of small nursing homes operating in Switzerland. Moreover, long-term care for the elderly is supplied by public, private for-profit and non-profit nursing homes, respectively.The paper presents an econometric estimation of a stochastic cost frontier using cross-section data for a sample of 886 Swiss nursing homes operating in 1998. The results of this analysis are used to examine the relationship between cost efficiency, the alternative institutional forms and the different regulatory settings.

Drugs, sex, money and power: an HPV vaccine case study.

In this paper we compare the experiences of seven industrialized countries in considering approval and introduction of the worlds first cervical cancer-preventing vaccine. Based on case studies, articles from public agencies, professional journals and newspapers we analyse the public debate about the vaccine, examine positions of stakeholder groups and their influence on the course and outcome of this policy process. The analysis shows that the countries considered here approved the vaccine and established related immunization programs exceptionally quickly even though there still exist many uncertainties as to the vaccines long-term effectiveness, cost-effectiveness and safety. Some countries even bypassed established decision-making processes. The voice of special interest groups has been prominent in all countries, drawing on societal values and fears of the public. Even though positions differed among countries, all seven decided to publicly fund the vaccine, illustrating a widespread convergence of interests. It is important that decision-makers adhere to transparent and robust guidelines in making funding decisions in the future to avoid capture by vested interests and potentially negative effects on access and equity.

Six Countries, Six Health Reform Models? Health Care Reform in Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands

Abstract This research contribution presents a diagnosis of the health reform experience of six small and mid-sized industrial democracies: Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands during the last decades of the twentieth century. It addresses the following questions: why have these six countries, facing similar pressures to reform their health care systems, with similar options for government action, chosen very different pathways to restructure their health care? What did they do? And what happened after the implementation of those reforms? The article describes the current arrangements for funding, contracting and payment, ownership and administration (or “governance”) of health care at the beginning of the twenty-first century, the origins of the health care reforms, the discussion and choice of policy options, processes of implementation and “after reform adjustments”. The article looks at factors that help explain the variety in reform paths, such as national politics, dominant cultural orientations and the positions of major stakeholders.

Equity, Access and Economic Evaluation in Rare Diseases. The Impact of Orphan Drug Legislation on Health Policy and Patient Care

Currently, there are in excess of 5000 rare diseases, that is, diseases that affect only a small proportion of a given population. The majority of these conditions lack appropriate treatments for a variety of reasons, including limited markets for the development of new pharmaceutical products coupled with prohibitively high costs associated with research, manufacturing and marketing. This paper discusses the issues associated with the equity of and access to orphan drugs used in rare diseases. Options for healthcare policy across Europe are presented. The interest in using robust evaluation parameters is emphasized, despite this not being in agreement with the use of artificial indicators such as quality-adjusted life years (QALYs), which appear to lead to divergent and erroneous results. New decision-making methods must govern the policy, statistics, and economics relevant to the use of orphan drugs in rare diseases.

The inequity of the Swiss health care system financing from a federal state perspective

IntroductionPrevious studies have shown that Swiss health-care financing is particularly regressive. However, as it has been emphasized in the 2011 OECD Review of the Swiss Health System, the inter cantonal variations of income-related inequities are still broadly unexplored. The present paper aims to fill this gap by analyzing the differences in the level of equity of health-care system financing across cantons and its evolution over time using household data.MethodsFollowing the methodology proposed by Wagstaff et al. (JHE 11:361–387, 1992) we use the Kakwani index as a summary measure of regressivity and we compute it for each canton and for each of the sources that have a role in financing the health care system. We graphed concentration curves and performed relative dominance tests, which utilize the full distribution of expenditures.The microdata come from the Swiss Household Income and Expenditure Survey (SHIES) based on a sample of the Swiss population (about 3500 households per year), for the years 1998 - 2005.ResultsThe empirical evidence confirms that the health-care financing in Switzerland has remained regressive since the major reform of 1996 and shows that the variations in equity across cantons are quite significant: the difference between the most and the least regressive canton is about the same as between two extremely different financing systems like the US and Sweden. There is no evidence, instead, of a clear evolution over time of regressivity.ConclusionsThe significant variation in equity across cantons can be explained by fiscal federalism and the related autonomy in the design of tax and social policies. In particular, the results highlight that earmarked subsidies, the policy adopted to smooth the regressivity of the premiums, appear to be not enough; in the practice of federal states the combination of allowances with mandatory community-rated health insurance premiums might lead to a modest outcome in terms of equity.

Six countries, six reform models : the healthcare reform : experience of Israel, the Netherlands, New Zealand, Singapore, Switzerland and Taiwan : healthcare reforms "under the radar screen"

Health Reform in Chile: From Military to Democratic Governance Health Reform in Israel: Partial Policy Implementation as Learning Opportunity Health Reform in The Netherlands: Change and Continuity Health Reform in New Zealand: Reform and Re-form Health Reform in Singapore: Willingness to Change and Pragmatism Health Reform in Switzerland: Privatizationj, Decentralization and Constraints of Federalism Health Reforms in Taiwan: Learning from International Experience and National Adjustments Conclusions: What to Make of the Reform Experiences? Empirical and Theoretical Findings.

Does the Swiss School of Public Health exist

‘‘Switzerland does not exist’’ or ‘‘La Suisse n’existe pas’’ was the statement the French artist Ben Vautier featured in the Swiss Pavilion at the World Exposition 1992 in Seville. It provoked an outcry in Switzerland, in particular in the political arenas of parliaments and the media. The Swiss School of Public Health (SSPH ?)—proud owner of the International Journal of Public Health—celebrated the 10th anniversary in 2015. Why would the SSPH? Directorate refer to Ben Vautier’s provocation to ask whether SSPH? does exist? As SSPH? moves into the second decade it will face the challenges of puberty and the years as a teenager. These are times of transitions, changes and reflections too. Table 1 summarizes the major achievements and highlights of the first 10 years of SSPH?. These successes, achieved under the leadership of the past Directors were also the result of the solid funding structure. SSPH?, initiated in July 2005 through funds from the Swiss University Conference (SUC), was transformed into a Foundation as of 2008. At that time, SSPH? expanded its network from six to eight Swiss universities, including all universities with major academic institutions of public health, namely Basel, Bern, Geneva, Lausanne, Lucerne, Lugano, Neuchâtel and Zurich. The SUC support for SSPH? was reserved for the first 12 years to then adopt a new financing model. Indeed, as of 2017, the SUC funds—in the past some 1–3 Mio CHF per year—will be replaced by a model where all the universities that carry SSPH? would become its direct funding bodies. This visionary model for a School of Public Health being a network of all academic public health constituencies rather than a classic central ‘‘school’’ is intriguing for a small country like Switzerland. The model gives a promising structure to strengthen public health in a country where excessively federalistic structures resulted so far in rather weak public health systems and infrastructures— comparable to the situation in Germany where an expert panel properly identified the need for strengthening the field (German National Academy of Sciences Leopoldina et al. 2015). Whether we will accomplish this goal in the next decade will depend on the future willingness to collaborate, which in turn will also depend on sustainable funds. At this stage, the foundation has neither been set on balanced nor stable grounds for its upcoming time as a teenager. As the budget will be lower than in the past and commitments of the eight university partners unequal (contributions of each university range between 5 and 60 % of the future budget) one primary strategic goal of the Directorate will be to strengthen the financial pillars of SSPH?. This Editorial was published on occasion of the 10th anniversary of the Swiss School of Public Health.

Modeling Cross-Border Care in the EU Using a Principal-Agent Framework

Cross-border care is likely to become a major issue among EU countries because patients have the option of obtaining treatment abroad under Community Regulations 1408/71. This paper develops a model formalizing both the patients decision to apply for cross-border care and the authorizing physicians decision to admit a patient to the program. The patient is assumed to maximize expected utility, which depends on the quality of care and the length of waiting in the home country and the host country, respectively. Not all patients qualifying for the EU program present themselves to the authorizing physician because of the transaction cost involved. The physician in her turn shapes effective demand for authorization through her rate of refusal, which constitutes information to potential applicants about the probability of obtaining treatment abroad. The authorizing physician thus acts as an agent serving two principals, her patient and her national government, trading off the perceived utility loss of patients who are rejected against her commitment to domestic health policy. The model may be used to explain existing patient flows between EU countries.