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Free patient mobility is not a free lunch. Lessons from a decentralised NHS

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  • S. Balia
  • Rinaldo Brau
  • E. Marrocu

Abstract

Patient mobility is a crucial phenomenon in contexts of hospital competition based on quality and driven by patient choice. This study examines inter-regional patient mobility in the Italian National Health Service, a regionally decentralised tax-funded system in which in-patient hospital services are provided free at any point of use in the whole country, using administrative data on hospital discharges from 2001 to 2010 in all public and private accredited hospitals. The aim is to understand whether mobility patterns might have consequences for the efficiency and effectiveness of the healthcare provided at the regional level, as well as universalism and equity in healthcare. We specify a gravity model for Origin-Destination (OD) flow data that distinguishes between emissiveness (at Origin) and attractiveness (at Destination) factors affecting bilateral flows. We exploit the longitudinal dimension of the data and estimate a negative binomial conditionally correlated random effects (CCRE) dynamic model that allows for region-pair-specific unobservable heterogeneity. Total and specific types of flow (surgical, medical, acute and cancer-related admissions) are modelled, accounting for the correlation between unobserved region-pair effects and time-variant covariates and their spatial lags. Our main findings indicate that RHSs in the richest regions attract more patients from other regions and that the most effective pull factors are the number of beds and diversification of the organisational structure. We also find that the ability of a RHS to attract patients who reside in other regions decreases with the concentration of the organizational structure. Finally, we have detected a mildly explosive dynamics in inter-regional patient mobility over time, which could have implications for the long-run sustainability of the overall national-regional health system.

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  • S. Balia & Rinaldo 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.
    • Handle: RePEc:cns:cnscwp:201409
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    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, June.
    3. 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.
    4. repec:ctc:serie1:def0009 is not listed on IDEAS
    5. Gaynor, Martin & Town, Robert J., 2011. "Competition in Health Care Markets," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 499-637, Elsevier.
    6. repec:ctc:serie1:def9 is not listed on IDEAS
    7. 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.
    8. J. Kornai & E. Maskin & G. Roland, 2004. "Understanding the Soft Budget Constraint," Voprosy Ekonomiki, NP Voprosy Ekonomiki, issue 11.
    9. Finocchiaro Castro, Massimo & Guccio, Calogero & Pignataro, Giacomo & Rizzo, Ilde, 2014. "The effects of reimbursement mechanisms on medical technology diffusion in the hospital sector in the Italian NHS," Health Policy, Elsevier, vol. 115(2), pages 215-229.
    10. Rosella Levaggi & Roberto Zanola, 2004. "Patients' migration across regions: the case of Italy," Applied Economics, Taylor & Francis Journals, vol. 36(16), pages 1751-1757.
    11. 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.
    12. 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.
    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. Chamberlain, Gary, 1982. "Multivariate regression models for panel data," Journal of Econometrics, Elsevier, vol. 18(1), pages 5-46, January.
    15. Kurt R. Brekke & Roberto Cellini & Luigi Siciliani & Odd Rune Straume, 2012. "Competition in Regulated Markets with Sluggish Beliefs about Quality," Journal of Economics & Management Strategy, Wiley Blackwell, vol. 21(1), pages 131-178, March.
    16. 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.
    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. Rosella Levaggi & Francesco Menoncin, 2008. "Fiscal Federalism, Patient Mobility and Soft Budget Constraint in Italy," Politica economica, Società editrice il Mulino, issue 3, pages 367-388.
    20. 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.
    21. 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.
    22. Brekke, Kurt R. & Siciliani, Luigi & Straume, Odd Rune, 2012. "Quality competition with profit constraints," Journal of Economic Behavior & Organization, Elsevier, vol. 84(2), pages 642-659.
    23. 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).
    24. Wallace Oates, 2005. "Toward A Second-Generation Theory of Fiscal Federalism," International Tax and Public Finance, Springer;International Institute of Public Finance, vol. 12(4), pages 349-373, August.
    25. 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.
    26. Mundlak, Yair, 1978. "On the Pooling of Time Series and Cross Section Data," Econometrica, Econometric Society, vol. 46(1), pages 69-85, January.
    27. Bordignon, Massimo & Turati, Gilberto, 2009. "Bailing out expectations and public health expenditure," Journal of Health Economics, Elsevier, vol. 28(2), pages 305-321, March.
    28. 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.
    29. Weingast, Barry R., 2009. "Second generation fiscal federalism: The implications of fiscal incentives," Journal of Urban Economics, Elsevier, vol. 65(3), pages 279-293, May.
    30. D A Griffith & K G Jones, 1980. "Explorations into the Relationship between Spatial Structure and Spatial Interaction," Environment and Planning A, , vol. 12(2), pages 187-201, February.
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    Keywords

    spatial dependence; nonlinear panel data methods; negative binomial regression; hospital admission; gravity model; decentralised health systems;
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