Vincenzo Rebba

VOLUNTARY PRIVATE HEALTH INSURANCE AMONG THE OVER 50s IN EUROPE

Using data from Survey of Health, Ageing and Retirement in Europe (SHARE), we investigate the determinants of voluntary private health insurance (VPHI) among the over 50s in 11 European countries and their effects on healthcare spending. First, we find that the main determinants of VPHI are different in each country, reflecting differences in the underlying healthcare systems, but in most countries, education levels and cognitive abilities have a strong positive effect on holding a VPHI policy. We also analyse the effect of holding a voluntary additional health insurance policy on out-of-pocket (OOP) healthcare spending. We adopt a simultaneous equations approach to control for self-selection into VPHI policy holding and find that, only in the Netherlands, VPHI policyholders have lower OOP spending than the rest of the population, whereas in some countries (Italy, Spain, Denmark and Austria), they spend significantly more. This could be due to not only increased utilisation but also cost-sharing measures adopted by the insurers to counter the effects of moral hazard and to keep adverse selection under control.

Healthier lifestyles after retirement in Europe? Evidence from SHARE

This paper investigates changes in health behaviours upon retirement, using data drawn from the Survey of Health Ageing and Retirement in Europe. By exploiting changes in eligibility rules for early and statutory retirement, we identify the causal effect of retiring from work on smoking, alcohol drinking, engagement in physical activity and visits to the general practitioner or specialist. We provide evidence about individual heterogeneous effects related to gender, education, net wealth, early-life conditions and job characteristics. Our main results––obtained using fixed-effect two-stage least squares––show that changes in health behaviours occur upon retirement and may be a key mechanism through which the latter affects health. In particular, the probability of not practicing any physical activity decreases significantly after retirement, and this effect is stronger for individuals with higher education. We also find that different frameworks of European health care systems (i.e. countries with or without a gate-keeping system to regulate the access to specialist services) matter in shaping individuals’ health behaviours after retirement. Our findings provide important information for the design of policies aiming to promote healthy lifestyles in later life, by identifying those who are potential target individuals and which factors may affect their behaviour. Our results also suggest the importance of policies promoting healthy lifestyles well before the end of the working life in order to anticipate the benefits deriving from individuals’ health investments.

Libertarian paternalism and health care policy: a deliberative proposal

Cass Sunstein and Richard Thaler have been arguing for what they named libertarian paternalism (henceforth LP). Their proposal generated extensive debate as to how and whether LP might lead down a full-blown paternalistic slippery slope. LP has the indubitable merit of having hardwired the best of the empirical psychological and sociological evidence into public and private policy making. It is unclear, though, to what extent the implementation of policies so constructed could enhance the capability for the exercise of an autonomous citizenship. Sunstein and Thaler submit it that in most of the cases in which one is confronted with a set of choices, some default option must be picked out. In those cases whoever devises the features of the set of options ought to rank them according to the moral principle of non-maleficence and possibly to that of beneficence. In this paper we argue that LP can be better implemented if there is a preliminary deliberative debate among the stakeholders that elicits their preferences, and makes it possible to rationally defend them.

Investment decisions in hospital technology when physicians are devoted workers

This paper analyses the decision to invest in a new technology (as a way to increase quality) by a hospital using a real option framework. The environment is characterised by uncertainty on costs and returns of such investment and by the assumption that physicians are ‘devoted workers’. We model the behaviour of three main actors: an agency purchasing hospital care (purchaser), a hospital (provider) and a representative hospital physician. The purchaser rewards the hospital at a fixed price for each patient treated and sets a quality-contingent long-term contract with the hospital according to a purchasing rule. First, we show that the presence of devoted physicians allows the hospital to reduce its investment while increasing the level of quality of care provided. We then analyse how the purchaser may influence the timing of the hospitals investment and the quality of care through strategic setting of the purchasing rule parameters. In particular, we show that if the purchaser aims at maximising overall quality of hospital care when physicians are devoted workers, it is not optimal to set a purchasing rule that cancels out the value of the option to defer the hospitals investment.

Waiting time prioritisation for specialist services in Italy: The homogeneous waiting time groups approach

The demand for referrals and diagnostic procedures in Italy has been rising constantly in recent years, making access to diagnostic services increasingly difficult with significant waiting times. A number of Health Authorities (known as Local Health Units) have responded by implementing formalised waiting-time prioritisation tools, giving rise to what are known as Homogeneous Waiting Groups (HWGs). The study describes the implementation of the HWG approach in Italy. This represents a promising tool for improving the prioritisation of patients waiting to see a specialist or to receive a diagnostic test. The study of the Italian HWG experience provides useful insights to improve the outpatient referral process for those countries where the demand prioritisation policies have focused more on inpatient care than outpatient specialist care and diagnostic services.

Invecchiamento della popolazione e spesa per il long-term care

prende un insieme di prestazioni monetarie e reali che non includono però la cura delle patologie acute e croniche. Le prestazioni reali di Ltc, che richiedono tipicamente un’interazione continua e coordinata tra servizi sanitari e socioassistenziali, si distinguono in tre tipologie a seconda che siano offerte al domicilio dell’utente, presso strutture residenziali o presso strutture intermedie (centri diurni). L’assistenza a domicilio assume diverse forme (ospedalizzazione domiciliare, assistenza domiciliare integrata, interventi di tipo socioassistenziale) ed è caratterizzata dal coinvolgimento della famiglia che spesso rappresenta la principale fonte di sostegno per gli anziani non autosufficienti. Tutti gli analisti concordano sul fatto che i trend demografici ed epidemiologici in atto accentueranno la domanda di assistenza sociosanitaria, e soprattutto di Ltc, ma quale sarà il probabile impatto dell’invecchiamento della popolazione sulla spesa sociosanitaria nel lungo periodo? Gli attuali sistemi pubblici di assistenza sanitaria e sociale saranno sostenibili in futuro? Come si sta attrezzando l’Italia rispetto ai nuovi bisogni di Ltc? Come vedremo, non è agevole rispondere a queste domande e anche le analisi più recenti, pur avendo portato apprezzabili avanzamenti sul piano metodologico, non sembrano offrire risposte definitive. Sembra quindi utile sviluppare ulteriormente la ricerca teorica ed empirica su queste complesse questioni.

Quality and Investment Decisions in Hospital Care when Physicians are Devoted Workers

This paper analyses the decision to invest in quality by a hospital in an environment where doctors are devoted workers, i.e. they care for specific aspects of the output they produce. We assume that quality is the result of both an investment in new technology and the effort of the medical staff. Hospital services are paid on the basis of their marginal cost of production while the number of patients treated depends on a purchasing rule which discriminates for the level and timing of the investment. We show that the presence of devoted doctors affects the trade-off between investment and the purchasing rule so that for the hospital it is not always optimal to anticipate the investment decision.

Cancer, obesity, and legitimation of suggested lifestyles: a libertarian paternalism approach

We know that around 30% of all cancers are preventable. We also know that there is clear evidence of the causal relations between obesity and cancer. This means that there could be lifestyles that could prevent obesity and, thus, cancer. Yet, who legitimises these lifestyles and on which ground? Should citizens be free to accept or not to accept policies concerning them? This is a problem faced within what has been named libertarian paternalism. We discuss it, also proposing a version that we call deliberative libertarian paternalism, showing how important this problem is for a proper framing of the lifestyle policies concerning obesity and, thus, cancer prevention.

Taking decisions on expenditure for high-cost drugs at the regional level: a model for evaluating the overall impact of Trastuzumab in the Veneto Region of Italy

INTRODUCTION Cost-effectiveness analysis provides a ratio that indicates the value created per unit of money by a given therapy but says nothing about the total expected costs or net health and social impact of this therapy in a particular population of interest. OBJECTIVE The main objective of this study is to define a methodology to calculate the effects of interventions from a local perspective. This will help determine parameters that provide information about resource planning and management to local decision makers. METHODS The described methodology calculates four indicators using local demographic and epidemiological data and a Markovian decision tree approach. RESULTS The method was applied to evaluate the economic, health and social impact of introducing a new cancer drug, Trastuzumab, for the early treatment of breast cancer in the Veneto Region of Italy. DISCUSSION The indicators described in this study allow public policy makers to clearly understand the benefits and costs of a particular health intervention in a local population and to compare it with other strategies.

Dalla teoria dei beni pubblici locali al federalismo funzionale

This paper illustrates some of the main results within local public finance, focusing on the relationships between local public goods (LPGs), club goods and fiscal federalism theories. The paper also considers competitive federalism and functional federalism, two models recently proposed in order to overcome the limits of traditional theories on LPGs and fiscal federalism. The analysis especially concentrates on functional federalism. Initially, section 2 gives a broad definition of local public goods (LPGs), pointing out the analogy between this category of collective goods and club goods. Section 3 analyzes the main contents of competitive models of LPGs supply developed by Tiebout, Buchanan and Berglas. Section 4 underlines the limits of these models and shows how many factors give rise to a LPGs market characterized by a restricted number of local jurisdictions. In section 5, after illustrating the fiscal equivalence principle, the fundamentals and the conceptual limits of traditional normative theory of fiscal federalism are exposed; moreover, it is shown how a model of competitive federalism could overcome the drawbacks of traditional normative approach, by resorting to some properties of the competitive models of LPGs allocation. Section 6 analyzes the theoretical foundations and some examples of the model of functional federalism; given the existing framework of local governments, functional federalism can minimize the shifting from the fiscal equivalence principle, being based on the formation - through cooperative agreements between individuals or local communities - of a system of single or multi-function jurisdictions each corresponding to a optimally sized club providing a LPG or a set of LPGs. Finally, section 7 suggests some directions for future research.