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Are primary care physicians, public and private sector specialists substitutes or complements? Evidence from a simultaneous equations model for count data


  • Atella, Vincenzo
  • Deb, Partha


In this paper, we examine the relationships between health care visits to general practitioners, public and private sector specialists using data from Italy, which has a mixed public-private health care system. We develop a simultaneous equations model that allows for the discreteness of measures of utilization and estimate this model using maximum simulated likelihood. Once common unobserved heterogeneity is properly accounted for, general practitioners, public and private specialists are found to be substitute sources of medical care. In contrast, a naive model finds they are complements.

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  • Atella, Vincenzo & Deb, Partha, 2008. "Are primary care physicians, public and private sector specialists substitutes or complements? Evidence from a simultaneous equations model for count data," Journal of Health Economics, Elsevier, vol. 27(3), pages 770-785, May.
  • Handle: RePEc:eee:jhecon:v:27:y:2008:i:3:p:770-785

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    References listed on IDEAS

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    Cited by:

    1. Daniele Fabbri & Chiara Monfardini, 2016. "Opt Out or Top Up? Voluntary Health Care Insurance and the Public vs. Private Substitution," Oxford Bulletin of Economics and Statistics, Department of Economics, University of Oxford, vol. 78(1), pages 75-93, February.
    2. Tugba Büyükdurmus & Thomas Kopetsch & Hendrik Schmitz & Harald Tauchmann, 2017. "On the interdependence of ambulatory and hospital care in the German health system," Health Economics Review, Springer, vol. 7(1), pages 1-19, December.
    3. van Dijk, Christel E. & Korevaar, Joke C. & Koopmans, Berber & de Jong, Judith D. & de Bakker, Dinny H., 2014. "The primary–secondary care interface: Does provision of more services in primary care reduce referrals to medical specialists?," Health Policy, Elsevier, vol. 118(1), pages 48-55.
    4. Chai Cheng, T., 2011. "Measuring the effects of removing subsidies for private insurance on public expenditure for health care," Health, Econometrics and Data Group (HEDG) Working Papers 11/32, HEDG, c/o Department of Economics, University of York.
    5. Del Vecchio, Mario & Fenech, Lorenzo & Prenestini, Anna, 2015. "Private health care expenditure and quality in Beveridge systems: Cross-regional differences in the Italian NHS," Health Policy, Elsevier, vol. 119(3), pages 356-366.
    6. Michela Ponzo & Vincenzo Scoppa, 2016. "Cost-Sharing and Use of Health Services in Italy: Evidence from a Fuzzy Regression Discontinuity Design," CSEF Working Papers 440, Centre for Studies in Economics and Finance (CSEF), University of Naples, Italy.
    7. Gächter, Martin & Schwazer, Peter & Theurl, Engelbert & Winner, Hannes, 2012. "Physician density in a two-tiered health care system," Health Policy, Elsevier, vol. 106(3), pages 257-268.
    8. Cheng, Terence Chai, 2014. "Measuring the effects of reducing subsidies for private insurance on public expenditure for health care," Journal of Health Economics, Elsevier, vol. 33(C), pages 159-179.
    9. Vincenzo Atella & Alberto Holly & Alessandro Mistretta, 2016. "Disentangling Adverse Selection, Moral Hazard and Supply Induced Demand: An Empirical Analysis of The Demand For Healthcare Services," CEIS Research Paper 389, Tor Vergata University, CEIS, revised 28 Jun 2016.
    10. Godager, Geir & Iversen, Tor & Ma, Ching-to Albert, 2015. "Competition, gatekeeping, and health care access," Journal of Health Economics, Elsevier, vol. 39(C), pages 159-170.
    11. Arnab Mukherji & Satrajit Roychowdhury & Pulak Ghosh & Sarah Brown, 2012. "Estimating Healthcare Demand for an Aging Population: A Flexible and Robust Bayesian Joint Model," Working Papers 2012027, The University of Sheffield, Department of Economics.
    12. Jeffrey E. Harris & Sandra G. Sosa-Rubi, 2009. "Impact of "Seguro Popular" on Prenatal Visits in Mexico, 2002-2005: Latent Class Model of Count Data with a Discrete Endogenous Variable," NBER Working Papers 14995, National Bureau of Economic Research, Inc.
    13. Chai Cheng, T & Vahid, F, 2010. "Demand for hospital care and private health insurance in a mixed publicprivate system: empirical evidence using a simultaneous equation modeling approach," Health, Econometrics and Data Group (HEDG) Working Papers 10/25, HEDG, c/o Department of Economics, University of York.
    14. Martin Gaechter & Peter Schwazer & Engelbert Theurl, 2013. "Entry into the Physicians’ Market: Empirical Evidence from the Outpatient Sector in Austria," DANUBE: Law and Economics Review, European Association Comenius - EACO, issue 4, pages 245-260, December.
    15. Marvasti, Akbar, 2014. "An estimation of the demand and supply for physician services using a panel data," Economic Modelling, Elsevier, vol. 43(C), pages 279-286.
    16. Kiranmoy Das & Bhuvanesh Pareek & Sarah Brown & Pulak Ghosh, 2017. "A Semiparametric Bayesian Approach to a New Dynamic Zero-Inflated Model," Working Papers 2017001, The University of Sheffield, Department of Economics.
    17. Massimo Baldini & Gilberto Turati, 2012. "Perceived quality of public services, liquidity constraints, and the demand of private specialist care," Empirical Economics, Springer, vol. 42(2), pages 487-511, April.
    18. Eva Hromadkova, 2009. "Gatekeeping – Open Door to Effective Medical Care Utilisation?," CERGE-EI Working Papers wp400, The Center for Economic Research and Graduate Education - Economics Institute, Prague.
    19. Anthony Scott & Stefanie Schurer & Paul H. Jensen & Peter Sivey, 2009. "The effects of an incentive program on quality of care in diabetes management," Health Economics, John Wiley & Sons, Ltd., vol. 18(9), pages 1091-1108.
    20. Fabbri, Daniele & Monfardini, Chiara, 2009. "Rationing the public provision of healthcare in the presence of private supplements: Evidence from the Italian NHS," Journal of Health Economics, Elsevier, vol. 28(2), pages 290-304, March.
    21. López Nicolás, Ángel & Vera-Hernández, Marcos, 2008. "Are tax subsidies for private medical insurance self-financing? Evidence from a microsimulation model," Journal of Health Economics, Elsevier, vol. 27(5), pages 1285-1298, September.
    22. Jason Shafrin, 2010. "Operating on commission: analyzing how physician financial incentives affect surgery rates," Health Economics, John Wiley & Sons, Ltd., vol. 19(5), pages 562-580.

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