Paula González

Optimal sharing of surgical costs in the presence of queues

Abstract.We deal with a cost-allocation problem arising from sharing a medical service in the presence of queues. We use a standard queuing theory model in a context of several medical procedures, a certain demand for treatment and a maximum average waiting-time guaranteed by the government. We show that the sharing of an operating-theatre to treat patients of different medical disciplines leads to a cost reduction. We then compute an optimal fee per procedure for the use of the operating theatre, based on the Shapley value. Afterwards, considering the recovery time, we characterize the conditions under which the co-operation among treatments has a positive impact on the post-operative costs. Finally, a numerical example, constructed on the basis of real data, is provided to highlight the main features of our model.

A theoretical approach to dual practice regulations in the health sector

Internationally, there is wide cross-country heterogeneity in government responses to dual practice in the health sector. This paper provides a uniform theoretical framework to analyze and compare some of the most common regulations. We focus on three interventions: banning dual practice, offering rewarding contracts to public physicians, and limiting dual practice (including both limits to private earnings of dual providers and limits to involvement in private activities). An ancillary objective of the paper is to investigate whether regulations that are optimal for developed countries are adequate for developing countries as well. Our results offer theoretical support for the desirability of different regulations in different economic environments.

Gatekeeping versus direct-access when patient information matters

We develop a principal-agent model in which the health authority acts as a principal for both a patient and a general practitioner (GP). The goal of the paper is to weigh the merits of gatekeeping versus non-gatekeeping approaches to health care when patient self-health information and patient pressure on GPs to provide referrals for specialized care are considered. We find that, when GPs incentives matter, a non-gatekeeping system is preferable only when (i) patient pressure to refer is sufficiently high and (ii) the quality of the patients self-health information is neither highly inaccurate (in which case the patients self-referral will be very inefficient) nor highly accurate (in which case the GPs agency problem will be very costly).

El pluriempleo entre los profesionales sanitarios: un análisis de sus causas e implicaciones

This paper reviews the most relevant literature on dual job holding among physicians. In doing this, we follow an appro- ach based in Economic Theory. The aim of this research is two-fold: First, we investigate the causes that lead some phy- sicians who work in the public sector to engage in private prac- tice. Secondly, we analyse the potential adverse consequen- ces of dual practice on efficiency in the provision of health services. We find that although doctors may be driven mainly by economic reasons, there are other factors such as job com- plementarities, as well as institutional, professional and per- sonal variables that may influence physician decisions on mo- onlighting. We also present and analyze the most relevant negative consequences of dual practice including: absente- eism, shirking, referral of patients, cream-skimming, and co- rruption.words: Physicians. Dual job holding. Incentives. Public-

Dual Practice by Health Workers: Theory and Evidence from Indonesia

Using a simple theoretical model we conjecture that dual practice may increase the number of patients seen but reduce hours spent at public facilities, if public physicians lack motivation and/or if their opportunity costs are very large. Using data from Indonesia, we then test these theoretical conjectures. Our identification strategy relies on a 1997 legislation necessitating health professionals to apply for license for private practice only after three years of graduation. Results using a difference-in-difference regression discontinuity design provides support to our conjectures, identifying the role of weak work discipline, lack of motivation and opportunity costs of public service provision.

Risk Attitudes in Medical Decisions for Others: An Experimental Approach

The aim of this paper is to investigate how risk attitudes in medical decisions for others vary across health contexts. A lab experiment was designed to elicit the risk attitudes of 257 medical and nonmedical students by assigning them the role of a physician who must decide between treatments for patients. An interval regression model was used to estimate individual coefficients of relative risk aversion, and an estimation model was used to test for the effect of type of medical decision and experimental design characteristics on elicited risk aversion. We find that (a) risk attitudes vary across different health contexts, but risk aversion prevails in all of them; (b) students enrolled in health-related degrees show a higher degree of risk aversion; and (c) real rewards for third parties (patients) make subjects less risk-averse. The results underline the importance of accounting for attitudes towards risk in medical decision making.

Implementing registries and results databases of clinical trials: is there a side effect?

Many parts of the world are currently witnessing a controversial discussion concerning the appropriate design of the environment for clinical trials. The catalyst of this debate has been a number of highly publicized cases in which pharmaceutical firms are accused of having selectively disclosed evidence on marketed drugs. Many participants in the discussion promote greater transparency in clinical trials and support the introduction of mandatory clinical trials registries and results databases. This report draws upon prior work by the authors analyzing the effects of these regulations on a pharmaceutical firm’s incentives to conduct clinical trials. Our findings add a new dimension to the discussion since they show the existence of a trade-off – as intended, registries and databases have the potential to increase transparency in clinical trials but they are likely to reduce the incentives to carry out clinical trials. This does not imply that these regulations are undesirable but it underlines the need for more research to be conducted on the incentive effects of these policies, because an informed policy choice must take into account all likely consequences of regulatory action and balance conflicting goals.