Marcello Montefiori

Spatial competition for quality in the market for hospital care

This study analyses the market for secondary health care services when patient choice depends on the quality/distance mix that achieves utility maximization. First, the hospital’s equilibrium in a Hotelling spatial competition model under simultaneous quality choices is analyzed to define hospitals’ strategic behavior. A first equilibrium outcome is provided, the understanding of which is extremely useful for the policy maker wishing to improve social welfare. Second, patients are assumed to be unable, because of asymmetry of information, to observe the true quality provided. Their decisions reflect the perceived quality, which is affected by bias. Using the mean-variance method, the equilibrium previously found is investigated in a stochastic framework.

It Takes Three to Tango: Soft Budget Constraint and Cream Skimming in the Hospital Care Market

Cream skimming is an illegal behaviour that consists in choosing to treat patients according to their ability to recover. It arises from the use of prospective payment schemes in an asymmetry of information framework. In this context in fact the provider can observe some relevant information (freely or at a cost) before making its effort which will then be used to its own advantage. The paper studies the scope for these types of behaviour in a mixed market for hospital care where the hospitals do not share the same objectives. We show that in this context cream skimming is made possible by the presence of two important elements: the public hospital prefers to treat high severity patients and the regulator is unable to enforce hard budget constraint rules. The paper adds an important dimension to the study of cream skimming as proposed by the traditional literature where asymmetry of information alone is considered the cause of this market failure. In our context, in fact, cream skimming arises mainly from a regulatory failure.

Information vs advertising in the market for hospital care

Recent health care reforms have introduced prospective payments and have allowed patients to choose their preferred providers. The expected outcome is efficiency in production and an increase in the quality level. The former objective should be obtained by the prospective payment scheme; the latter by the demand mechanism, through the competition between providers. Unfortunately, because of asymmetry of information, patients are unable to observe the true quality and the demand for health care services depends on a perceived quality as influenced by the hospital advertising. Inefficiency in the resource allocation and social welfare loss are the two likely effects. In this paper we show how the purchaser can implement effective policies to overcome these undesired effects.

Quality of life of people living with HIV, preliminary results from IANUA (Investigation on Antiretroviral Therapy) study

The introduction of combined antiretroviral treatment (cART) has reduced HIV‐associated morbidity and mortality, and changed the patients’ perspective of life. As a result, Health Related Quality of Life (HRQOL) has become a crucial clinical issue.

Hospital Emergency Department: An Insight by Means of Quantitative Methods

In this work we will examine the activity of the Emergency Department (ED) of an Italian primary Hospital by way of real data. Data will be analyzed both via econometrics and data mining (namely: dimensions reduction) models. Our findings demonstrate that using a quantitative exploratory approach to the study of ED data makes it possible to gain suitable information for both the hospitals management and the policymaker, hence contributing to a better understanding of EDs activity and to address its accurate programming. The new approach we suggest is intended to put at decision- maker disposal a set of tools that surfing on the available data make it possible to skim the very relevant information (and hence to reject negligible elements) extracting from the whole set of determinants only those of effective relevance. This, in our opinion, could be a key issue to both verifying the actual performance, and to put forth new policies to improve efficiency and quality as well.

Targeting frequent users of emergency departments: Prominent risk factors and policy implications

This study investigates the characteristics of frequent users of accident and emergency departments (AEDs) and recommends alternative medical services for such patients. Prominent demographic and clinical risk factors for individuals accessing seven AEDs located in the metropolitan area of Genoa, Italy are identified and analysed. A truncated count data model is implemented to establish the determinants of access, while a multinomial logistic regression is used to highlight potential differences among different user categories. According to previous studies, empirical findings suggest that despite the relevance of demographic drivers, vulnerability conditions (e.g. abuse of alcohol and drugs, chronic conditions, and psychological distress) are the main reasons behind frequent AED use; the analysis seems to confirm an association between AED frequent use and lower level of urgency. Since frequent and highly frequent users are found responsible for disproportionate resource absorption with respect to total amount of AED costs (they represent roughly 10% of the total number of patients, but contribute to more than 19% of the total annual AED cost), policies aiming to reduce frequent use of AEDs could bring significant savings in economic resources. Thus, efficient actions could be oriented toward extending primary care services outside AED and toward instituting local aid services specifically addressed to people under the influence of substances or in conditions of mental distress.

Popular initiatives in 2014–2016 call for the introduction of mandatory dental care insurance in Switzerland: The contrasting positions at stake ☆

Switzerlands mandatory health insurance system provides coverage for a standard benefits package for all residents. However, adult dental care is covered only in case of accidents and inevitable dental illnesses, while routine dental care is almost completely financed out-of-pocket. In general, unmet health needs in Switzerland are low, but unmet dental needs are significant, when compared with other countries in Europe. Recent popular initiatives in Switzerland have aimed to introduce a mandatory insurance model for dental care through a mandatory contribution of 1% of gross salaries toward dental care insurance. In three cantons, the proposals have collected the required number of signatures and a public referendum is expected to be held in 2017/2018. If implemented, the insurance system is expected to have a significant impact on the dental profession, dental care demand, and the provision of dental services. The contrasting positions of stakeholders for and against the reform reflect a rare situation in which dental care policy issues are being widely discussed at all levels. However, such a discussion is of crucial relevance not only for Switzerland, but also for the whole of Europe, which has significant levels of unmet needs for dental care, especially among vulnerable and deprived individuals, and new solutions to expand dental care coverage are required.

Robustness and Effectiveness of the Triage System in the Pediatric Context

BackgroundThe increasing use of emergency departments (EDs) potentially compromises their effectiveness and quality. The evaluation of the performance of the triage code system in a pediatric context is important because waiting time affects the quality of care for acutely ill patients.ObjectiveIn this study, we aimed to assess the effectiveness and robustness of the triage code system in a pediatric context and identify the determinants of waiting times for urgent and non-urgent patients.MethodsData regarding 37,767 pediatric patients who accessed the ED of a major Italian pediatric hospital in 2015 were investigated in order to study patient numbers and waiting times. The determinants of waiting times for urgent and non-urgent patients, as well as variables referring to the “supply side,” such as periods of staff shortage, were analyzed using a survival analysis framework.ResultsFor urgent patients, the waiting time between triage and the first physician assessment is generally below the standard threshold of 15 min and this is not affected by the number of non-urgent patients waiting for care. Conversely, the waiting time for non-urgent patients is affected by ED flow, periods of staff shortage, and non-clinical variables (age and nationality).ConclusionOur results suggest that the triage level assignation system is effective in terms of safety for urgent patients. The current ED organization adequately fulfills its primary goal of providing healthcare for acutely ill patients.

What should we expect from Switzerland’s compulsory dental insurance reform?

BackgroundA vast and heated debate is arising in Switzerland as a result of some recent citizens’ initiatives aimed at introducing compulsory dental health care insurance. The Grand Conseils of the Vaud, Geneva, and Neuchâtel cantons recently approved three public initiatives and their citizens are expected to vote on the proposal in 2018. The process of collecting signatures has begun in several other cantons and the discussion has now moved to a national level.DiscussionAt present, there is no scientific research that can help policy-makers and citizens to understand the main economic implications of such reform. We attempt to fill this gap by analysing three critical issues: the level and determinants of unmet needs for dental care in Switzerland; the protection of vulnerable individuals; and the economic sustainability of reform.Results and short conclusionsThe results show that income is not a unique determinant of barriers to access to dental care but rather, cultural and socio-demographic factors impact the perceived level of unmet dental care needs. The reform might only partially, if at all, improve the equity of the current system. In addition, the results show that the 1% wage-based contribution that the reform promoters suggest should finance the insurance is inadequate to provide full and free dental care to Swiss residents, but is merely sufficient to guarantee basic preventive care, whereas this could be provided by dental hygienists for less.

Analisi socio-economica degli accessi ripetuti al pronto soccorso pediatrico: il caso dell’Istituto G. Gaslini di Genova

The use of Emergency Departments (EDs) is continuously increasing and the challenge of guaranteeing an efficient and effective service is threatened by the phenomena of inappropriate and frequent use. Most of the literature on the topic focuses on adult population; in this study we analyse the issue of frequent use of ED among paediatric patients, with the aim of detecting the most significant socio-demographic and clinical predictors of frequent use of emergency services. Results, based on data collected from the ED of one of the most important paediatric Italian Hospital, show that children aged less than 12 months, foreign and chronic patients (particularly those suffering from mental illness, respiratory diseases and circulatory system problems) have a higher risk of becoming frequent and highly frequent ED users. It emerges that frequent users, although they only represent the 8% of total number of accesses, they account for 19% of total costs.