nep-hea New Economics Papers
on Health Economics
Issue of 2009‒01‒17
twenty-two papers chosen by
Yong Yin
SUNY at Buffalo, USA

  1. The Italian hospital system By Maurizio Lozzi
  2. The difficult access to childcare in Italy: the determinants from the supply and the demand side By Francesco Zollino
  3. Migration of Health Workers: The UK Perspective to 2006 By James Buchan; Susanna Baldwin; Miranda Munro
  4. The Remuneration of General Practitioners and Specialists in 14 OECD Countries: What are the Factors Influencing Variations across Countries? By Rie Fujisawa; Gaetan Lafortune
  5. The US Physician Workforce: Where Do We Stand? By Richard Cooper
  6. Pharmaceutical Pricing and Reimbursement Policies in Germany By Valérie Paris; Elizabeth Docteur
  7. International Mobility of Health Professionals and Health Workforce Management in Canada: Myths and Realities By Jean-Christophe Dumont; Pascal Zurn; Jody Church; Christine Le Thi
  8. Competition among Health Plans: A Two-Sided Market Approach By David Bardey; Jean-Charles Rochet
  10. Projecting the Future Numbers of Migrant Workers in the Health and Social Care Sectors in Ireland By Barrett, Alan; Rust, Anna
  11. The Games We Used to Play: An Application of Survival Analysis to the Sporting Life-course By Lunn, Pete
  12. Population Ageing: Crisis or Opportunity? By Ermisch J
  13. Disability benefits and paying for care By Berthoud R; Hancock R
  14. Intrafamily Resource Allocations: A Dynamic Model of Birth Weight By Del bono E; Ermisch J; Francesconi M
  15. Nutritional Contributions of Nonalcoholic Beverages to the U.S. Diet: 1998-2003 By Dharmasena, Senarath; Capps Jr., Oral; Clauson, Annette
  16. Part-Time Sick Leave as a Treatment Method? By Andrén, D; Andrén, T
  17. The geography of hospital admission in a National Health Service with patient choice: evidence from Italy. By Fabbri, D; Robone, S
  18. Re-visiting the Health Care Luxury Good Hypothesis: Aggregation, Precision, and Publication Biases? By Costa-Font, J; Gemmill, M; Rubert, G
  19. The Effects of Pharmaceutical Marketing and Promotion on Adverse Drug Events and Regulation By Guy David; Sara Markowitz; Seth Richards
  20. Recent Trends in Height by Gender and Ethnicity in the US in Relation to Levels of Income By John Komlos
  21. Life (evaluation), HIV/AIDS, and Death in Africa By Angus Deaton; Jane Fortson; Robert Tortora
  22. Life Expectancy and Old Age Savings By Mariacristina De Nardi; Eric French; John Bailey Jones

  1. By: Maurizio Lozzi (Banca d'Italia)
    Abstract: Over the last decade two reforms have affected the Italian hospital system, one introducing market mechanisms, the other concerning the tools of planning and expense control assigned to the regional governments. The paper summarizes these institutional changes and describes the evolution of the structure and the activity of the hospital system, with a focus on the differences between regions. It highlights the following: (1) the reduction in the number of hospitals and hospital beds and the gap between regions in terms of hospital beds per capita; (2) the growth in personnel compared with the number of hospital beds; (3) the stationarity of admissions since the end of the nineties and the growth in the share of those in day hospital; (4) the greater number of admissions in southern regions, especially for inappropriate or less complex treatment, and the high level of migration towards northern hospitals; (5) with reference to costs, increasing returns to scale up to a given hospital size, which is larger, the more complex the courses of treatment provided; (6) the differences between regions in costs which are affected by the size of facilities and their type of specialization.
    Keywords: hospitals, sanitary system, hospital performances, hospital costs
    JEL: H75 I11 I18
    Date: 2008–09
  2. By: Francesco Zollino (Banca d'Italia)
    Abstract: Assembling information from several sources and a drawing on specially designed new survey, this paper finds that the shortfall in the supply of child care facilities remains large with respect to potential demand but is less severe with respect to the effective demand by households in Italy. Controlling for individual characteristics and local external environment, empirical evidence points to the key role played by the cost-quality schedule in supporting formal care. Local governments exert a significant influence on this factor through multiple channels, such as the intensity of regulation on quality standards, the degree of flexibility in the service provision, and the financing and tariff policies. These channels differ widely across geographical areas. The local set-up can give rise to contrasting effects on both the profitability of private childcare providers, who hardly fill the potential gap in the public network, and on household demand, which could benefit to a limited extent from a greater availability of facilities in case these are of unsatisfactory quality.
    Keywords: childcare facilities, welfare policies, geographical differences
    JEL: D1 H75 J13
    Date: 2008–09
  3. By: James Buchan; Susanna Baldwin; Miranda Munro
    Abstract: The UK has a population of 56 million, and most healthcare is delivered through the National Health Service (NHS). The NHS employs more than one million staff. In the late 1990s shortages of skilled staff were a main obstacle to improving services in the NHS. The response by government was to “grow” the NHS workforce. There are four main policy options to “grow” the workforce- increase home based training; improve retention rates of current staff (to reduce need to recruit additional staff); improve “return” of staff currently not practising; and internationally recruit health professionals. International recruitment was used to achieve rapid growth in the NHS workforce. It was facilitated by fast tracking work permits for health professionals, by targeting recruits in specified countries, using specialist recruitment agencies, and by co-ordinating local level recruitment within the NHS (...)<BR>Le Royaume-Uni compte 56 millions d’habitants, et en matière de santé, la plupart des prestations y sont fournies par le biais du National Health Service (NHS). Le NHS emploie plus d’un million d’agents. A la fin des années 90, un des principaux obstacles à l’amélioration du NHS était la pénurie de personnel qualifié. La réponse du gouvernement a consisté à « étoffer » les effectifs du NHS. Pour ce faire, les pouvoirs publics disposent de quatre grands moyens d’action possibles : développer la formation dispensée dans le pays même, améliorer le taux de maintien des agents en poste (ce qui permet de diminuer les besoins en recrutement de nouveaux agents), convaincre les agents ayant cessé d’exercer pour le moment de « reprendre du service », et recruter des professionnels de la santé à l’international. Soucieux d’étoffer rapidement ses effectifs, le NHS a eu recours au recrutement à l’international. L’opération a été facilitée par l’application de la procédure de traitement accéléré des demandes de permis de travail pour les professionnels de la santé, par le ciblage des personnes à recruter dans des pays précis (en faisant appel à des agences de recrutement spécialisées), et par la coordination du recrutement au niveau local au sein du NHS (...)
    Date: 2008–10–13
  4. By: Rie Fujisawa; Gaetan Lafortune
    Abstract: This paper provides a descriptive analysis of the remuneration of doctors in 14 OECD countries for which reasonably comparable data were available in OECD Health Data 2007 (Austria, Canada, the Czech Republic, Denmark, Finland, France, Germany, Hungary, Iceland, Luxembourg, Netherlands, Switzerland, the United Kingdom and the United States). Data are presented for general practitioners (GPs) and medical specialists separately, comparing remuneration levels across countries both on the basis of a common currency (US dollar, adjusted for purchasing power parity) and in relation to the average wage of all workers in each country.<BR>Ce document de travail présente une analyse descriptive de la rémunération des médecins dans 14 pays de l’OCDE pour lesquels on trouve des données raisonnablement comparables dans Eco-santé OCDE 2007 (Allemagne, Autriche, Canada, Danemark, États-Unis, Finlande, France, Hongrie, Islande, Luxembourg, Pays-Bas, République tchèque, Royaume-Uni et Suisse). Les données sont présentées séparément pour les généralistes (omnipraticiens) et les spécialistes. La comparaison des niveaux de rémunération entre pays est faite sur la base d’une monnaie commune (le dollar américain, ajusté pour la parité des pouvoirs d’achat), ainsi qu’en rapport avec le salaire moyen de l’ensemble des travailleurs dans chacun des pays.
    Date: 2008–12–18
  5. By: Richard Cooper
    Abstract: This review surveys trends in physician supply in the United States from 1980 to the present with particular attention to the participation of International Medical Graduates. It discussed the composition of the physician workforce with regards to the number of family practitioners, specialists, women physicians and the aging of the workforce. Changes in the inflows and outflows of the physician workforce are discussed and, in particular, how international migration, retirement, part-time practice and alternative employment have impacted the physician workforce.<BR>La présente étude consistait à observer l’évolution de l’offre de médecins aux États-Unis de 1980 à nos jours, en accordant une attention particulière aux médecins diplômés étrangers. On y examine la composition du corps médical, dont le nombre de médecins de famille, de spécialistes, de femmes médecins, ainsi que la question de son vieillissement. On y réfléchit sur l’évolution des flux d’entrées et de sorties de médecins en activité et, en particulier, sur la manière dont les migrations internationales, les départs à la retraite, l’exercice à temps partiel et la possibilité d’exercer un autre emploi ont influé sur cette population.
    Keywords: absolute poverty
    JEL: I19 J61
    Date: 2008–10–13
  6. By: Valérie Paris; Elizabeth Docteur
    Abstract: This paper describes pharmaceutical pricing and reimbursement policies in Germany, considering them in the broader environment in which they operate, and assesses their impact on the achievement of a number of policy goals. Pharmaceutical coverage is comprehensive, with a high level of public funding, and ensures access to treatments. However, recent increases in out-of-pocket payments may impair affordability for the poorest part of the population. Germany does not regulate ex-manufacturer prices of pharmaceuticals at market entry (though distribution margins are regulated for reimbursed drugs). On the other hand, maximum reimbursement amounts (known as reference prices) are set for products which can be clustered in groups of equivalent (generic) or comparable products (...)<BR>Ce document décrit les politiques de prix et de remboursement des médicaments en Allemagne, en les replaçant dans le contexte plus large dans lequel elles s’insèrent, et évalue leur impact sur l’atteinte de plusieurs objectifs. La couverture des médicaments par l’assurance maladie est bonne, caractérisée par un haut niveau de prise en charge publique, et permet un bon accès aux traitements. Cependant, les augmentations récentes des paiements à la charge des usagers pourraient entraver l’accessibilité financière pour les populations les plus modestes. L’Allemagne ne régule pas les prix fabricant des médicaments à leur entrée sur le marché, mais seulement les marges des distributeurs pour les médicaments pris en charge par l’assurance maladie. D’un autre côté, des montants maximum de remboursement (souvent nommés “prix de référence ") sont fixés pour les produits qui peuvent être rassemblés au sein de groupes de produits équivalents (génériques) ou comparables.
    JEL: I11 I18
    Date: 2008–10–21
  7. By: Jean-Christophe Dumont; Pascal Zurn; Jody Church; Christine Le Thi
    Abstract: This report examines the role played by immigrant health workers in the Canadian health workforce but also the interactions between migration policies and education and health workforce management policies. Migrant health worker makes a significant contribution to the Canadian health workforce. Around 2005-06, more than 22% of the doctors were foreign-trained and 37% were foreign-born. The corresponding figures for nurses are close to 7.7% and 20%, respectively. Foreign-trained doctors play an important role in rural areas as they contribute to filling the gaps. In most rural areas, on average, 30% of the physicians were foreign-trained in 2004. Over past decades the evolution of the health workforce in Canada has been characterised notably by a sharp decline in the density of nurses and a stable density of doctors, which is in contrast with the trends observed in other OECD countries. This evolution is largely the result of measures were adopted at the end of the 1980s and early 1990s in order to address a perceived health workforce surplus.<BR>Ce rapport examine le rôle joué par la migration de personnel de santé dans les effectifs de santé au Canada mais aussi les interactions entre les politiques migratoires, la formation et les politiques de gestion de ressources humaines. Le personnel de santé recruté à l’étranger contribue de façon significative aux effectifs de santé au Canada. En 2005-06, plus de 22 % des médecins au Canada sont formés à l’étranger et 37 % d’entre eux sont nés à l’étranger. Respectivement pour les infirmières, la part des personnes formées à l’étranger est de 7.7 % et celle des personnes nées à l’étranger de 20%. Les médecins formés à l’étranger jouent un rôle important dans des zones rurales ayant contribué à réduire au manque d’effectif dans les zones rurales. En 2004, dans la plupart des zones rurales, en moyenne 30 % des médecins sont formés à l’étranger. Au cours des dernières décennies, l’évolution des effectifs de santé au Canada a été marquée notamment par un net déclin de la densité des infirmières et par une densité stable des médecins, ce qui contraste avec les tendances observées dans les pays de l’OCDE. Cette évolution est largement due aux mesures adoptées à la fin des années 80 et au début des années 90 afin de répondre au surplus perçu d’effectif de personnel de santé.
    Date: 2008–10–16
  8. By: David Bardey; Jean-Charles Rochet
    Abstract: Classical analysis of health insurance markets often focuses on adverse selection, which creates a direct externality between the enrollees of the same health plan: under an imperfect risk adjustment, the higher the risks of my co-enrollees, the higher my cost of insurance. This has lead to the view that restricting the diversity of accessible physicians may be good for policyholders, in a context where competition between health plans can lead to a "death spiral" for the less restrictive plan. This paper defends the opposite view that diversity might pay, because of the indirect externality between policyholders and physicians. By attracting higher risks, the less restrictive plan may also guarantee a higher level of activity to its physicians, and therefore negotiate with them a lower fee-for-service rate. By explicitly modeling the two sides of the market for health (policyholders and physicians), we are able to …find examples in which competition between health plans gives a higher pro…fit to the less restrictive plan.
    Date: 2009–01–08
  9. By: Luis Fernando Gamboa; Nohora Forero Ramírez
    Abstract: We analyze the Body Mass Index (BMI) in a distinct way of its traditional use and it lets us use it as a proxy of standard of living for the case of Colombia. Our approach is focused on studying how far the people are from the normal range and not on the score of each one and this lets us to treat equally extreme cases as severe thinness and obesity. We use a probabilistic model (Ordered Probit) that evaluates the probability of being within the normal range or another level. We found that socioeconomic variables have a significant effect on the dependent variable and that there are no linear effects. Besides, people with difficulties for walking and adults have less probability of having a normal BMI.
    Date: 2009–01–08
  10. By: Barrett, Alan (ESRI); Rust, Anna (ESRI)
    Abstract: Ireland will experience population ageing in the coming years, whereby the percentage of the population aged 65 and over will rise from its current level of 11 percent to over 20 percent in 2035. A number of papers have looked at the implications of this process for the public finances. However, less attention has been paid to the human resource needs that will arise if increased demands are placed on health and social care systems. In this paper, we provide projections of the possible numbers that will be needed to work in the health and social care sectors out to 2035. We also consider what proportion of the extra employees will be migrants. We discuss both practical and ethical issues which arise when foreign health and social care workers are recruited.
    Date: 2009–01
  11. By: Lunn, Pete (ESRI)
    Abstract: In the absence of longitudinal data, recall data is used to examine participation in sport. Techniques of survival analysis are adapted and applied to illuminate the dynamics of sporting life. The likelihood of participation has a distinct pattern across the life-course, rising to a peak at 15 years of age, falling sharply in late teenage years and more gradually during adulthood. Logistic regressions and Cox regressions reveal strong effects on participation of gender, cohort and socioeconomic status, which vary over the life-course and by type of sport. The findings add significantly to previous work and have implications for policymakers wishing to increase physical activity.
    Keywords: Sporting participation/Health/Survival analysis/Recall data
    Date: 2009–01
  12. By: Ermisch J (Institute for Social and Economic Research)
    Abstract: Population ageing reduces the working population relative to the number of pensions by one-third over next 30 years. The challenge presented by this development is how best to support pensionersÂ’ incomes without suppressing the net incomes of the working population and capital accumulation too much. The ability of private savings and occupational pensions to meet this challenge is doubtful. There is a related issue of inter-generational equity: how do we share the burden of population ageing between generations, rather than passing it on to future generations. Given the uncertainty about future demographic and economic developments, it is important to have adaptable or self-correcting policies to address population ageing.
    Date: 2008–11–18
  13. By: Berthoud R (Institute for Social and Economic Research); Hancock R (School of Medicine, Health Policy and Practice, University of East Anglia)
    Abstract: The Attendance Allowance (AA) and the Disability Living Allowance care component (DLAc) are paid to elderly and/or disabled people who need help with activities of daily living Together, these benefits cost £9.2 billion per year Since the need for care is the main criterion entitling people to claim, one important question is whether they receive (enough) care. The Wanless review recommended integrating support for care costs from these disability benefits into the care system to improve targeting of resources. This paper discusses the impact of AA/DLAc on the well-being of disabled adults, and assesses the likely advantages, and disadvantages, of a possible reallocation of resources
    Date: 2008–12–01
  14. By: Del bono E (Institute for Social and Economic Research); Ermisch J (Institute for Social and Economic Research); Francesconi M (Department of Economics, University of Essex)
    Abstract: This paper estimates a model of dynamic intrahousehold investment behavior which incor- porates family fixed effects and child endowment heterogeneity. This framework is applied to large American and British survey data on birth outcomes, with focus on the effects of antenatal parental smoking and maternal labor supply net of other maternal behavior and child characteristics. We find that maternal smoking during pregnancy reduces birth weight and fetal growth, while paternal smoking has virtually no effect. Mothers' work interruptions of up to two months before birth have a positive effect on birth outcomes, especially among British children. Parental behavior appears to respond to permanent family-specific unobservables and to child idiosyncratic endowments in a way that suggests that parents have equal concerns, rather than efficiency motives, in allocating their prenatal inputs across children. Evidence of equal concerns emerges also from the analysis of breastfeeding decisions, although the effects in this case are weaker.
    Date: 2008–09–16
  15. By: Dharmasena, Senarath; Capps Jr., Oral; Clauson, Annette
    Keywords: nonalcoholic beverages, nutritional elements, calories, calcium, vitamin C, caffeine, and econometric analysis, Consumer/Household Economics, Food Consumption/Nutrition/Food Safety,
    Date: 2009
  16. By: Andrén, D; Andrén, T
    Abstract: This paper analyzes the effects of being on part-time sick leave compared to full-time sick leave on the probability of recovering (i.e., returning to work with full recovery of lost work capacity). Using a discrete choice one-factor model, we estimate mean treatment parameters and distributional treatment parameters from a common set of structural parameters. Our results show that part-time sick leave increases the likelihood of recovering and dominates full-time sick leave for sickness spells of 150 days or longer. For these long spells, the probability of recovering increases by 10 percentage points.
    Keywords: part-time sick leave, selection, unobserved heterogeneity, treatment effects
    JEL: I12 J21 J28
    Date: 2009–01
  17. By: Fabbri, D; Robone, S
    Abstract: It is evaluated that, each year, 35% out of the 10 million hospital admissions in Italy take place outside the LHAs of residence. In our paper we try to give an explanation of this phenomenon making reference to the social gravity model of spatial interaction. We estimate gravity equations using a Poisson pseudo maximum likelihood method, as proposed by Santos-Silva and Tenreyro (2006). Our results suggest that the gravity model is a good framework for explaining the patient mobility phenomenon for most of the examined diagnostic groups. Our evidence suggests that the ability to contain the imports of hospital services increases with the size of the pool of enrolees. Moreover we find that the ability to export hospital services, as proxied by the ratio of export-to-internal demand, is U-shaped. Therefore our evidence suggests that there are scale effect played by the size of the pool of enrolees.
    Keywords: patients’ mobility, hospital care, gravity model, Italian National Health Service
    Date: 2008–12
  18. By: Costa-Font, J; Gemmill, M; Rubert, G
    Abstract: While a growing literature examining the relationship between income and health expenditures suggests that health care is a luxury good, this conclusion is contentiously debated due to heterogeneity of the existing results. This paper tests the luxury good hypothesis (namely that income elasticity exceed unity) using meta-regression analysis, taking into consideration publication selection and aggregation bias. The findings suggest that publication bias exists, a result that is robust to the meta-regression model employed. Publication selection and aggregation bias also appear to play a role in the generation of estimates. The corrected income elasticity estimates range from 0.4 to 0.8, which cast serious doubt on the validity of luxury good hypothesis. Nonetheless, due to the importance of aggregation, we cannot reject the luxury good hypothesis for aggregate time series data.
    Keywords: meta-regression analysis, health care, luxury good, income elasticity, aggregate health expenditure, regional health expenditure
    JEL: I1 I10 I11 I18
    Date: 2009–01
  19. By: Guy David; Sara Markowitz; Seth Richards
    Abstract: This paper analyzes the relationship between postmarketing promotional activity and reporting of adverse drug events by modeling the interaction between a welfare maximizing regulator (the FDA) and a profit maximizing firm. In our analysis demand is sensitive to both promotion and regulatory interventions. Promotion-driven market expansions enhance profitability yet may involve the risk that the drug would be prescribed inappropriately, leading to adverse regulatory actions against the firm. The model exposes the effects of the current regulatory system on consumer and producer welfare. Particularly, the emphasis on safety over benefits distorts the market allocation of drugs away from some of the most appropriate users. We then empirically test the relationship between drug promotion and reporting of adverse reactions using an innovative combination of commercial data on pharmaceutical promotion and FDA data on regulatory interventions and adverse drug reactions. We provide some evidence that increased levels of promotion and advertising lead to increased reporting of adverse medical events for certain conditions.
    JEL: I1 K0 K2
    Date: 2009–01
  20. By: John Komlos
    Abstract: Height trends since World War II are analyzed using the most recent NHANES survey released in 2006. After declining for about a generation, the height of adult white men and women began to increase among the birth cohorts of c. 1975-1986, i.e., those who reached adulthood within the past decade (1995-2006). The increase in their height overcame the prior downturn that lasted between ca. 1965 and 1974. The height gap between white and black men has increased by only 0.43 cm (0.17 in.) during past decade compared to the previous quarter century to reach 1.0 cm (0.39 in.). However, the height of black women has been actually declining absolutely by 1.42 cm (0.56 in.) and relative to that of white women. Black women of the most recent birth cohort are (at 162.3 cm, 63.9 in.) shorter than almost all Western-European women including Spain and Italy. As a consequence, a very considerable wedge has developed between black and white women's height of 1.95 cm (0.77 in.). The decline in their height is most likely related to the obesity epidemic caused by inadequate dietary balance. Black women in the age range 20-39 weigh some 9.5 kg (21.0 lb) more than their white counterparts. It appears that black females are experiencing a double jeopardy in the sense that both their increasing weight and the diminution of their physical stature are both substantial and are both probably associated with negative health consequences.
    JEL: I1 I31
    Date: 2009–01
  21. By: Angus Deaton; Jane Fortson; Robert Tortora
    Abstract: We use data from the Gallup World Poll and from the Demographic and Health Surveys to investigate how subjective wellbeing (SWB) is affected by mortality in sub-Saharan Africa, including mortality from HIV/AIDS. The Gallup data provide direct evidence on Africans' own emotional and evaluative responses to high levels of infection and of mortality. By comparing the effect of mortality on SWB with the effect of income on SWB, we can attach monetary values to mortality to illuminate the often controversial question of how to value life in Africa. Large fractions of the respondents in the World Poll report the mortality of an immediate family member in the last twelve months, with malaria typically more important than AIDS, and deaths of women in childbirth more important than deaths from AIDS in many countries. A life evaluation measure (Cantril's ladder of life) is relatively insensitive to the deaths of immediate family, which suggests a low value of life. There are much larger effects on experiential measures, such as sadness and depression, which suggest much larger values of life. It is not clear whether either of these results is correct, yet our results demonstrate that experiential and evaluative measures are not the same thing, and that they cannot be used interchangeably as measures of "happiness" in welfare economics.
    JEL: I12 J17 O15
    Date: 2009–01
  22. By: Mariacristina De Nardi; Eric French; John Bailey Jones
    Abstract: Rich people, women, and healthy people live longer. We document that this heterogeneity in life expectancy is large, and we use an estimated structural model to assess its effect on the elderly's saving. We find that the differences in life expectancy related to observable factors such as income, gender, and health have large effects on savings, and that these factors contribute by similar amounts. We also show that the risk of outliving one's expected lifespan has a large effect on the elderly's saving behavior.
    JEL: D1 D31 D91 E2 E21 E6 H31 I1
    Date: 2009–01

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