IDEAS home Printed from https://ideas.repec.org/p/wiw/wiwrsa/ersa16p127.html
   My bibliography  Save this paper

A spatial analysis of inter-regional patient mobility in Italy

Author

Listed:
  • Emanuela Marrocu
  • Silvia Balia
  • Rinaldo Brau

Abstract

Free patient mobility among autonomous providers has been often considered an effective stimulus for enhancing healthcare. However, some jurisdictions may underperform due to the existence of economies of scale and spatial spillovers. Where regions assume the costs of providing care to residents, this could challenge the sustainability of regional budgets in a decentralised National Health Service (NHS) and put at risk universalism and equity of health care. We use a ten years (2001-2010) panel of Italian data on hospital discharges to assess the determinants of inter-regional mobility and to distinguish between factors related with policies pursued by the regional health authorities from extra-regional (neighbouring regions or national-level) factors. Data on hospital discharges are merged with a set of variables on salient features of hospital care services in each Regional Health System (RHS) and with information on demographic and economic characteristics of Italian regions. We analyse bilateral Origin-to-Destination (OD) flows between any two regions by means of a gravity regression model that includes a rich set of push and pull factors. Compared to previous studies, mainly performed on cross-section samples, the longitudinal dimension of the data enables us to estimate a nonlinear conditionally correlated random effects dynamic model that accounts for region-pair-specific unobservable heterogeneity. Moreover, we address the issue of cross-regional dependence arising from the existence of regional spillovers by applying recent advances in spatial econometrics (Elhorst, 2014; Vega and Elhorst, 2015). The model is estimated for total inter-regional patient flows and for specific types of hospital admission, namely surgery, medicine and cancers. Finally, the estimation results are used to analyse specific what-if scenarios relevant to the health authorities for the national and sub-national management of services. Our main results suggest that, beside regional population and income, local supply factors such as hospital capacity and technology endowment, clinical specialization and performance indicators are important drivers of patient mobility. Moreover, geography matters and spatial proximity plays a relevant role in reinforcing inter-regional mobility patterns. Our econometric analysis has also detected a mildly explosive dynamics in inter-regional patient mobility over time. This result, coupled with the significant role played by factors not directly controlled by regional policy-makers and RHS managers (e.g. population, GDP per capita and spatial spillovers), might induce a polarisation between the group of the richest, most populated and best performing regions, which are increasingly capable of attracting more patients, and the group of the weakest regions, with growing patient outflows and severe financial and organizational problems. These considerations call for a thorough assessment of the long-run sustainability of the current decentralised NHS. RHS budget autonomy could not be entirely consistent with free patient choice. This opens a more general discussion on whether and to what extent the health financing system would require the introduction of appropriate equalising compensation schemes aimed at neutralising the financial consequences of mobility and, eventually, at guaranteeing universalism and equity in healthcare.

Suggested Citation

  • Emanuela Marrocu & Silvia Balia & Rinaldo Brau, 2016. "A spatial analysis of inter-regional patient mobility in Italy," ERSA conference papers ersa16p127, European Regional Science Association.
  • Handle: RePEc:wiw:wiwrsa:ersa16p127
    as

    Download full text from publisher

    File URL: https://www-sre.wu.ac.at/ersa/ersaconfs/ersa16/Paper127_EmanuelaMarrocu.pdf
    Download Restriction: no
    ---><---

    References listed on IDEAS

    as
    1. Daniele Fabbri & Silvana Robone, 2010. "The geography of hospital admission in a national health service with patient choice," Health Economics, John Wiley & Sons, Ltd., vol. 19(9), pages 1029-1047, September.
    2. Cameron,A. Colin & Trivedi,Pravin K., 2013. "Regression Analysis of Count Data," Cambridge Books, Cambridge University Press, number 9781107667273, October.
    3. Rosella Levaggi & Francesco Menoncin, 2013. "Soft budget constraints in health care: evidence from Italy," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 14(5), pages 725-737, October.
    4. Brekke, Kurt R. & Siciliani, Luigi & Straume, Odd Rune, 2008. "Competition and waiting times in hospital markets," Journal of Public Economics, Elsevier, vol. 92(7), pages 1607-1628, July.
    5. Jeffrey M. Wooldridge, 2005. "Simple solutions to the initial conditions problem in dynamic, nonlinear panel data models with unobserved heterogeneity," Journal of Applied Econometrics, John Wiley & Sons, Ltd., vol. 20(1), pages 39-54, January.
    6. Jeffrey M Wooldridge, 2010. "Econometric Analysis of Cross Section and Panel Data," MIT Press Books, The MIT Press, edition 2, volume 1, number 0262232588, December.
    7. Nicolas Debarsy, 2012. "The Mundlak Approach in the Spatial Durbin Panel Data Model," Spatial Economic Analysis, Taylor & Francis Journals, vol. 7(1), pages 109-131, March.
    8. Brekke, Kurt R. & Levaggi, Rosella & Siciliani, Luigi & Straume, Odd Rune, 2014. "Patient mobility, health care quality and welfare," Journal of Economic Behavior & Organization, Elsevier, vol. 105(C), pages 140-157.
    9. Rosella Levaggi & Roberto Zanola, 2004. "Patients' migration across regions: the case of Italy," Applied Economics, Taylor & Francis Journals, vol. 36(16), pages 1751-1757.
    10. James P. LeSage & R. Kelley Pace, 2008. "Spatial Econometric Modeling Of Origin‐Destination Flows," Journal of Regional Science, Wiley Blackwell, vol. 48(5), pages 941-967, December.
    11. Matteo Lippi Bruni & Lucia Nobilio & Cristina Ugolini, 2008. "The analysis of a cardiological network in a regulated setting: a spatial interaction approach," Health Economics, John Wiley & Sons, Ltd., vol. 17(2), pages 221-233, February.
    12. Chamberlain, Gary, 1982. "Multivariate regression models for panel data," Journal of Econometrics, Elsevier, vol. 18(1), pages 5-46, January.
    13. Cellini, Roberto & Brekke, Kurt Richard & Siciliani, Luigi, 2008. "Competition and quality in regulated markets with sluggish demand," CEPR Discussion Papers 6938, C.E.P.R. Discussion Papers.
    14. Mundlak, Yair, 1978. "On the Pooling of Time Series and Cross Section Data," Econometrica, Econometric Society, vol. 46(1), pages 69-85, January.
    15. James P. LeSage & Christine Thomas-Agnan, 2015. "Interpreting Spatial Econometric Origin-Destination Flow Models," Journal of Regional Science, Wiley Blackwell, vol. 55(2), pages 188-208, March.
    16. Shinjo, Daisuke & Aramaki, Toshiharu, 2012. "Geographic distribution of healthcare resources, healthcare service provision, and patient flow in Japan: A cross sectional study," Social Science & Medicine, Elsevier, vol. 75(11), pages 1954-1963.
    17. Marcello Montefiori, 2005. "Spatial competition for quality in the market for hospital care," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 6(2), pages 131-135, June.
    18. David Cantarero, 2006. "Health care and patients’ migration across Spanish regions," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 7(2), pages 114-116, June.
    19. Simona Baldi & Davide Vannoni, 2017. "The impact of centralization on pharmaceutical procurement prices: the role of institutional quality and corruption," Regional Studies, Taylor & Francis Journals, vol. 51(3), pages 426-438, March.
    20. Adolph, Christopher & Greer, Scott L. & Massard da Fonseca, Elize, 2012. "Allocation of authority in European health policy," Social Science & Medicine, Elsevier, vol. 75(9), pages 1595-1603.
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. S. Balia & R. Brau & E. Marrocu, 2014. "Free patient mobility is not a free lunch. Lessons from a decentralised NHS," Working Paper CRENoS 201409, Centre for North South Economic Research, University of Cagliari and Sassari, Sardinia.
    2. Berta, Paolo & Guerriero, Carla & Levaggi, Rosella, 2021. "Hospitals’ strategic behaviours and patient mobility: Evidence from Italy," Socio-Economic Planning Sciences, Elsevier, vol. 77(C).
    3. Paolo Berta & Gianmaria Martini & Daniele Spinelli & Giorgio Vittadini, 2022. "The beaten paths effect on patient inter‐regional mobility: An application to the Italian NHS," Papers in Regional Science, Wiley Blackwell, vol. 101(4), pages 945-977, August.
    4. Paolo Berta & Carla Guerriero & Rosella Levaggi, 2018. "The dark side of fiscal federalism:evidence from hospital care in Italy," Working papers 72, Società Italiana di Economia Pubblica.
    5. Tesfaye, Wondimagegn & Tirivayi, Nyasha, 2020. "Crop diversity, household welfare and consumption smoothing under risk: Evidence from rural Uganda," World Development, Elsevier, vol. 125(C).
    6. Mark Musumba & Cheryl A. Palm & Adam M. Komarek & Patrick K. Mutuo & Bocary Kaya, 2022. "Household livelihood diversification in rural Africa," Agricultural Economics, International Association of Agricultural Economists, vol. 53(2), pages 246-256, March.
    7. Elenka Brenna & Federico Spandonaro, 2014. "Does federalism induce patients’ mobility across regions? Evidence from the Italian experience," DISCE - Working Papers del Dipartimento di Economia e Finanza def009, Università Cattolica del Sacro Cuore, Dipartimenti e Istituti di Scienze Economiche (DISCE).
    8. Felipa De Mello-Sampayo, 2016. "A Spatial Analysis of Mental Healthcare in Texas," Spatial Economic Analysis, Taylor & Francis Journals, vol. 11(2), pages 152-175, June.
    9. Claudio Pinto, 2017. "Perceived quality and formation of inter-regional networks of health care migration," Advances in Management and Applied Economics, SCIENPRESS Ltd, vol. 7(3), pages 1-5.
    10. Raffaele Brancati & Emanuela Marrocu & Manuel Romagnoli & Stefano Usai, 2018. "Innovation activities and learning processes in the crisis: evidence from Italian export in manufacturing and services," Industrial and Corporate Change, Oxford University Press, vol. 27(1), pages 107-130.
    11. Ping Yu & Shengjie Hong & Peter C. B. Phillips, 2022. "Panel Threshold Regression with Unobserved Individual-Specific Threshold Effects," Cowles Foundation Discussion Papers 2352, Cowles Foundation for Research in Economics, Yale University.
    12. repec:ctc:serie1:def9 is not listed on IDEAS
    13. Garbero, A. & Marion, P., 2018. "IFAD RESEARCH SERIES 28 - Understanding the dynamics of adoption decisions and their poverty impacts: the case of improved maize seeds in Uganda," IFAD Research Series 280077, International Fund for Agricultural Development (IFAD).
    14. Badi H. Baltagi & Peter Egger & Michael Pfaffermayr, 2014. "Panel Data Gravity Models of International Trade," CESifo Working Paper Series 4616, CESifo.
    15. Fattore, Giovanni & Petrarca, Giuseppina & Torbica, Aleksandra, 2014. "Traveling for care: Inter-regional mobility for aortic valve substitution in Italy," Health Policy, Elsevier, vol. 117(1), pages 90-97.
    16. Li, Liyao & Yang, Zhenlin, 2021. "Spatial dynamic panel data models with correlated random effects," Journal of Econometrics, Elsevier, vol. 221(2), pages 424-454.
    17. Lippi Bruni, Matteo & Mammi, Irene & Ugolini, Cristina, 2016. "Does the extension of primary care practice opening hours reduce the use of emergency services?," Journal of Health Economics, Elsevier, vol. 50(C), pages 144-155.
    18. Lionel WILNER, 2019. "The Dynamics of Individual Happiness," Working Papers 2019-18, Center for Research in Economics and Statistics.
    19. Arnd Kölling & Claus Schnabel, 2022. "Owners, external managers and industrial relations in German establishments," British Journal of Industrial Relations, London School of Economics, vol. 60(2), pages 424-443, June.
    20. Erika Raquel Badillo & Rosina Moreno, 2016. "Are Collaborative Agreements in Innovation Activities Persistent at the Firm Level? Empirical Evidence for the Spanish Case," Review of Industrial Organization, Springer;The Industrial Organization Society, vol. 49(1), pages 71-101, August.
    21. Vigren, Andreas, 2020. "The Distance Factor in Swedish Bus Contracts How far are operators willing to go?," Transportation Research Part A: Policy and Practice, Elsevier, vol. 132(C), pages 188-204.

    More about this item

    Keywords

    regional health systems; hospital admissions; gravity model; nonlinear gravity panel model; spatial spillovers;
    All these keywords.

    JEL classification:

    • C23 - Mathematical and Quantitative Methods - - Single Equation Models; Single Variables - - - Models with Panel Data; Spatio-temporal Models
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health
    • H75 - Public Economics - - State and Local Government; Intergovernmental Relations - - - State and Local Government: Health, Education, and Welfare
    • R23 - Urban, Rural, Regional, Real Estate, and Transportation Economics - - Household Analysis - - - Regional Migration; Regional Labor Markets; Population
    • R50 - Urban, Rural, Regional, Real Estate, and Transportation Economics - - Regional Government Analysis - - - General

    NEP fields

    This paper has been announced in the following NEP Reports:

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:wiw:wiwrsa:ersa16p127. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Gunther Maier (email available below). General contact details of provider: http://www.ersa.org .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.