Matteo Lippi Bruni

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.

Economic incentives in general practice: The impact of pay-for-participation and pay-for-compliance programs on diabetes care

OBJECTIVES We investigate the impact on quality of care of the introduction of two financial incentives in primary care contracts in the Italian region Emilia Romagna: pay-for-participation and pay-for-compliance with best practices programs. METHODS We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of general practitioners (GPs) receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examine the combined influence of physician, organisational and patient factors by means of multilevel modelling for the year 2003. RESULTS Programs aimed at stimulating GP assumption of responsibility in disease management significantly reduce the probability of hyperglycaemic emergencies for their patients. CONCLUSIONS Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence healthcare outcomes. Our results support the hypothesis that financial transfers may contribute to improve quality of care, even when they are not based on the ex-post verification of performances.

The role of GP’s compensation schemes in diabetes care: evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

Public vs private demand for covering long term care expenditures

This article studies the determinants of the Willingness to Pay (WTP) for Long-Term Care (LTC) insurance coverage. Two alternatives are considered: one compulsory, financed through taxes, the other purchased on a voluntary basis and paid through a premium. WTP was elicited through open-ended contingent valuation within a survey conducted in the Italian region Emilia-Romagna about LTC population needs. We model information on individual WTP as a two-stage process, where respondents first establish their interest for LTC cover, then state their WTP. Results show that interest and WTP are influenced by different variables, and that differences arise also between the WTP for public and private coverage.

Economic Incentives in General Practice: The Impact of Pay for Participation Programs on Diabetes Care

Financial incentives are increasingly adopted to improve allocative efficiency and quality in primary care. Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence healthcare outcomes and on the degree of physicians’ responsiveness to their introduction. This problem reflects the lack of adequate empirical data but also the complexity of general practice systems where many confounding and institutional factors are likely to influence physician behaviour. Given this background, we investigate the impact on quality of care of the introduction of payfor- participation incentives in primary care contracts in the Italian region Emilia Romagna. We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of GPs receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examined the combined influence of physician, organisational and patient factors through the use of multilevel modelling. Data were obtained form a large dataset made available by the Regional Agency for Health Care Services of Emilia Romagna. This dataset covers patients and GPs of the whole region and provides detailed information on healthcare consumption of the population, on the different components of GP remunerations, on morbidity levels of large groups of patients. Estimations are obtained for the year 2003.

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.

Assistenza a domicilio e assistenza residenziale: politiche di intervento e analisi empirica

Although in Italy most Long-Term Care is still provided in kind by unpaid informal caregivers, families are less and less likely to be in the condition to care for a disabled elderly. Given the social and financial implications associated with this trend, there is a growing interest in understanding the determinants of family decisions regarding living arrangements of the elderly, in order to implement effective policy measures aimed at containing costs and to enhance the quality of care. We estimate the effects of various household and individual characteristics on the choice of living care arrangement, considering a representative population sample of the Italian region Emilia Romagna. We exploit detailed information on the health conditions of the elderly person, on household socio-economic status and on family attitudes towards current welfare state services in order to identify the main determinants of the choice between institutionalisation and home care. Our results outline the predominance of disability indicators as opposed to family characteristics, economic variables and public services availability in determining the decision of the family. In an context in which social norms about filial responsibility still tend to consider the elderly institutionalisation with a consistent amount of social stigma, the institutionalisation is strictly influenced by the growing functional or cognitive impairments of the elderly and, to a lower extent, by economic status. Partly different from the international empirical literature, wealthier households have a larger probability to opt for the residential alternative

Delegating Home Care for the Elderly to External Caregivers? An Empirical Study on Italian Data

We study care arrangement decisions in Italy, where families are increasingly delegating the role of primary caregiver to external (paid) people also for the provision of home care. We consider a sample of households with a dependent elderly person cared for either at home or in a residential home, extracted from a survey representative of the population of Italy’s Emilia-Romagna region. We investigate the determinants of a household’s decision to opt for one of the following three alternatives: the institutionalisation of elderly family members, informal home care, or paid home care. We estimate two model specifications, based on a simultaneous and a sequential decision process respectively, the results of which are fairly consistent. Disability related variables, rather than family characteristics, emerge as the main determinants of institutionalisation. On the other hand, household characteristics and socio-economic variables are more influential when it comes to choosing between informal and formal home care provisions.

Disentangling the effect of waiting times on hospital choice: Evidence from a panel data analysis

This study examines the effect of waiting times on hospital choice by using patient-level data on elective Percutaneous Transluminal Coronary Angioplasty (PTCA) procedures in the Italian NHS over the years 2008-2011. We perform a multinomial logit analysis including conditional logit and mixed logit specifications. Our findings show the importance of jointly controlling for time-invariant and time varying dimensions of hospital quality in order to disentangle the effect of waiting times on hospital choice. We provide evidence that patients are responsive to changes in waiting times and aspects of clinical quality within hospitals over time, and estimate the trade-off that patients make between different hospital attributes. The results convey important policy implications for highly regulated health care markets.

Spatial Effects in Hospital Expenditures: A District Level Analysis

We use spatial econometric methods to analyse spillovers in hospital expenditures across Health Districts of the Emilia-Romagna Region (Italy). We estimate spatial models that allow for global spillovers and distinguish between the expenditures associated with potentially inappropriate hospitalizations and those associated with complex medical procedures. We also investigate the relative contribution of geographical and institutional proximity in explaining spatial dependence, by explicitly modelling different connectivity structures and exploiting them to build alternative spatial weight matrices. We find that interactions largely differ between types of expenditures, with positive spatial effects for potentially inappropriate admissions, the effect being generally not significant for high-complexity expenditure. Relying on the estimated direct and indirect effects, we also test for the presence of spatial spillovers across districts. Finally, the paper draws policy implications for the public health planner.