SELECTED FOR YOU... FEBRUARY 2012:
books of the month
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BOOKS OF THE MONTH

OECD Reviews of Health Systems: Switzerland 2011.

Organisation de Coopération et de Développement Economiques. (O.C.D.E.).
Paris : OCDE : 2011 : 179 p.

Five years after the first Review of Switzerland's health system, the OECD and the World Organization combined their expertise again to report on progress and implementation of health reforms in the Swiss health system. In addition to taking stock of the good overall performance of the Swiss health system, the two organizations propose concrete ways to help the system be more efficient and prepare for the future health needs of the Swiss population. The report focuses on three important issues: health insurance markets, health workforce planning and management and governance of the health system.

WORKING PAPERS

Health Care Insurance

Medicaid and the elderly.
Le Medicaid et les personnes agées.

De Nardi M., French E., Bailey Johns J.
Cambridge : NBER : 2011/12 : 34 p.

This paper describes the Medicaid eligibility rules for the elderly. Medicaid is administered jointly by the Federal and state governments, and each state has significant flexibility on the details of the implementation. It documents the features common to all states, but we also highlight the most salient state-level differences. There are two main pathways to Medicaid eligibility for people over age 65: either having low assets and income, or being impoverished due to large medical expenses. The first group of recipients (the categorically needy) mostly includes life-long poor individuals, while the second group (the medically needy) includes people who might have earned substantial amounts of money during their lifetime but have become impoverished by large medical expenses. The categorically needy program thus only affects the savings decision of people who have been poor throughout most of their lives. In contrast, the medically needy program provides some insurance even to people who have higher income and assets. Thus, this second pathway is to some extent going to affect the savings of the relatively higher income and assets people.

Health Economics

Estimating the Costs of Specialised Care:Updated Analysis Using Data for 2009/10.
Estimation des coûts des soins spécialisés : une analyse réactualisée qui utilise des données 2009-2010.

Daidone S., Smith A.
York : University of York : 2011/11 : 26 p.

We were commissioned by the Department of Health's Payment by Results (PbR) team to use 2009/10 data update the analysis we performed using 2008/9 data to estimate the marginal costs of providing specialised care (Daidone and Street, 2011). The objectives of the original work were to investigate: 1. Whether the costs associated with specialised activity are significantly different from nonspecialised activity within the same HRG; 2. Whether any differences in costs between specialised and non-specialised activity are due to differences in productive efficiency. The objective of the update is: 1. To see whether the results obtained on the 2008-09 data are robust to 2009-10 data. 2. To investigate whether there is a case for differentiating payment on the basis of marginal cost differences arising when patients transferred between providers.

Keep it Simple? Predicting Primary Health Care Costs with Measures of Morbidity and Multimorbidity.
Faire simple ? Prédire les coûts des soins de santé primaires avec des mesures de la morbidité et de la multimorbidité.

Brilleman S.L., Gravelle H., Hollinghurst S. et al.
York : University of York : 2011/11 : 23 p.

This paper investigates the relationship between patients' primary care costs (consultations, tests, drugs) and their age, gender, deprivation and alternative measures of their morbidity and multimorbidity. Such information is required in order to set capitation fees or budgets for general practices to cover their expenditure on providing primary care services. It is also useful to examine whether practices' expenditure decisions vary equitably with patient characteristics. Electronic practice record keeping systems mean that there is very rich information on patient diagnoses. But the diagnostic information (with over 9000 possible diagnoses) is too detailed to be practicable for setting capitation fees or practice budgets. Some method of summarizing such information into more manageable measures of morbidity is required. This paper therefore compared the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs using data on 86,100 individuals in 174 English practices. The measures were derived from four morbidity descriptive systems (17 chronic diseases in the Quality and Outcomes Framework (QOF), 17 chronic diseases in the Charlson scheme, 114 Expanded Diagnosis Clusters (EDCs), and 68 Adjusted Clinical Groups (ACGs)). We found that, in general, for a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power and that measures with more categories did better than those with fewer. The EDC measures performed best, followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Allowing for individual patient morbidity greatly reduced the association of age and cost. There was a pro-deprived bias in expenditure: after allowing for morbidity, patients in areas in th e highest deprivation decile had costs which were 22% higher than those in the lowest deprivation decile. The predictive ability of the best performing morbidity and multimorbidity measures was very good for this type of individual level cross section data, with R2 ranging from 0.31 to 0.46. The statistical method of estimating the relationship between patient characteristics and costs was less important than the type of morbidity measure. Rankings of the morbidity and multimorbidity measures were broadly similar for generalised linear models with log link and Poisson errors and for OLS estimation. It would be currently feasible to combine the results from our study with the data on the number of patients with each QOF disease, which is available on all practices in England, to calculate budgets for general practices to cover their primary care costs.

Health Status

The French Unhappiness Puzzle: The Cultural Dimension of Happiness.
L'énigme du malheur français : La dimension culturelle du bonheur.

Senik C.
Bonn : IZA : 2011/11 : 58 p.

This article sheds light on the important differences in self-declared happiness across countries of equivalent affluence. It hinges on the different happiness statements of natives and immigrants in a set of European countries to disentangle the influence of objective circumstances versus psychological and cultural factors. The latter turns out to be of non-negligible importance in explaining international heterogeneity in happiness. In some countries, such as France, they are responsible for 80% of the country's unobserved idiosyncratic source of (un)happiness.

Exploring Determinants of Subjective Wellbeing in OECD Countries.
Exploration des déterminants du bien-être subjectif au sein des pays de l'OCDE.

Fleche S., Smith C., Sorsa P.
Paris : OCDE : 2011 : 39 p.

The paper explores issues with assessing wellbeing in OECD countries based on self-reported life satisfaction surveys in a pooled regression over time and countries, at the country level and the OECD average. The results, which are in line with previous studies of subjective wellbeing, show that, apart from income, the state of health, not being unemployed, and social relationships are particularly important for wellbeing with only some differences across countries. The results also show that cultural differences are not major drivers of differences in life satisfaction. Correlations between the rankings of measures of life satisfaction and other indicators of wellbeing such as the Human Development Index and Better Life Index are also relatively high. Measures of subjective wellbeing can play an important part in informing policy makers of progress with wellbeing in general, or what seems to matter for wellbeing— health, being employed and social contacts- beyond income.

Hospital

Does Prospective Payment Increase Hospital (In)Efficiency? Evidence from the Swiss Hospital Sector.
Le système de paiement prospectif augmente-t-il l'(in)efficicence de l'hôpital. Résultats issus du secteur hospitalier. suisse.

Widmer P.K.
Rochester : Social Science Electronic Publishing : 2011/12 : 23 p.

Several European countries have followed the United States in introducing prospective payment for hospitals with the expectation of achieving cost efficiency gains. This article examines whether theoretical expectations of cost efficiency gains can be empirically confirmed. In contrast to previous studies, the analysis of Switzerland provides a comparison of a retrospective per diem payment system with a prospective global budget and a payment per patient case system. Using a sample of approximately 90 public financed Swiss hospitals during the years 2004 to 2009 and Bayesian inference of a standard and a random parameter frontier model, cost efficiency gains are found, particularly with a payment per patient case system. Payment systems designed to put hospitals at operating risk are more effective than retrospective payment systems. However, hospitals are heterogeneous with respect to their production technologies, making a random parameter frontier model the superior specification for Switzerland.

Innovative procedures: the key factor for hospital performance.
Les procédures innovantes sont le facteur clé de la performance hospitalière.

Gobillon L., Milcent C.
Paris : Paris School of economics : 2011/12 : 8 p.

The role of innovative procedures in the mortality differences between university, non-teaching public and for-profit hospitals is investigated using a French exhaustive administrative dataset on patients admitted for heart attack. Mortality is roughly similar in the three types of hospitals after controlling for case-mix. For-profit hospitals treat the at-risk oldest patients more often with innovative procedures. Therefore, additionnally controlling for innovative procedures makes them having the highest mortality rate. Non-teaching public hospitals end up having the lowest mortality rate.

Accounting for Heterogeneity in the Measurement of Hospital Performance.
Prise en compte de l'hétérogenéité dans la mesure de la performance hospitalière.

Widmer P.K., Zweifel P., Farsi M.
Rochester : Social Science Electronic Publishing: 2011 : 29 p.

Health inequalities

Education and Health: Insights from International Comparisons.
Education et santé : éclairages à partir de comparaisons internationales.

Cutler D.M., Lleras-Muney A.
Cambridge : NBER : 2012/01 : 30 p.

This review synthesizes what is known about the relationship between education and health. A large number of studies from both rich and poor countries show that education is associated with better health. While previous work has thought of the effect of education separately for rich and poor countries, we argue that there are insights to be gained by integrating the two. For example, education is associated with lower malnutrition in most countries, but in richer countries the educated have lower BMIs whereas in poor countries the educated have higher BMIs. This suggests that the behaviors associated with better health differ depending on the level of development. This paper illustrates this approach by comparing the effects of education on various health and health behaviors around the world, to generate hypotheses about why education is so often (but not always) predictive of health. Finally, it reviews the empirical evidence on the relationship between education and health, paying particular attention to causal evidence and evidence on mechanisms linking education to better health.

Drugs

Assessing the impact of antibiotic policies in Europe.
Evaluation de l'impact des politiques concernant les antibiotiques en Europe.

Filippini M., Gonzalez Ortiz L.G., Masiero G.
Martigny : RERO : 2011/11 : 23 p.

Because of evidence of causal association between antibiotic use and bacterial resistance, the implementation of national policies has emerged as a interesting tool for controlling and reversing bacterial resistance. The aim of this study is to assess the impact of public policies on antibiotic use in Europe using a differences-in-differences approach. Comparable data on systemic administered antibiotics in 21 European countries are available for a 11-years panel between 1997 and 2007. Data on national campaigns are drawn from the public health literature. We estimate an econometric model of antibiotic consumption with country fixed effects and control for the main socioeconomic and epidemiological factors. Lagged values and the instrumental variables approach are applied to address endogeneity aspects of the prevalence of infections and the adoption of national campaigns. It found evidence that public campaigns significantly reduce the use of antimicrobials in the community by 1.4 to 3.7 defined daily doses per 1000 inhabitants. This roughly represents an impact between 7.2% and 18.5% on the mean level of antibiotic use in Europe between 1997 and 2007. The effect is robust across different measurement methods. Further research is needed to investigate the effectiveness of policy interventions targeting different social groups such as general practitioners or patient.

Primary health care

Keep it Simple? Predicting Primary Health Care Costs with Measures of Morbidity and Multimorbidity.
Faire simple ? Prédire les coûts des soins de santé primaires avec des mesures de la morbidité et de la multimorbidité

Brilleman S.L., Gravelle H., Hollinghurst S. et al.
York : University of York : 2011/11 : 23 p.

Transforming primary care in Ireland: information, incentives, and provider capabilities.
Transformer les soins primaires en Irlande : informations, incitations financières et aptitude des fournisseurs de soins.

Ryan P.
Rochester : Social Science Electronic Publishing : 2011/12 : 64 p.

Ireland's health system is at a key turning point. The Irish government was newly elected in February 2011, and the policy directions adopted over the coming months will likely exert a major impact on system performance for many years. Drawing on recent international experience with performance measurement and financial incentives, this paper examines strategies for enhancing quality and value in the Irish health system, focusing predominantly on the role of primary care.Three take-home messages emerge from the literature. First, substantial improvements in quality of care often can be attained at a reasonable cost, such as through the use of checklists and evidence-based clinical pathways, or by better aligning the skills of health care providers to patients' need. Second, rigorous performance measurement is a vital tool for quality improvement that is lacking in Ireland, and this could be particularly powerful if underpinned by risk-adjustment to enable reliable evaluation of clinical outcomes. Pilot projects are required to examine the feasibility of these techniques in the Irish context. Third, although pay-for-performance is a prominent quality improvement strategy, little evidence exists to support its purported benefits and it can exert negative effects. Incentives are unlikely to be effective if providers lack the capability to respond appropriately, therefore it is imperative to foster professionalism and pride in high-quality care, and to develop the managerial and clinical skills necessary for high performance.

Profit or Patients' Health Benefit? Exploring the Heterogeneity in Physician Altruism.
A son profit ou au bénéfice de la santé du patient ? Exploration de l'hétérogéneité de l'altruisme du médecin.

Godager G., Wiesen D.
Oslo : HERO : 2011 : 16 p.

This paper investigates physician altruism toward patients' health benefit using behavioral data from the fully incentivized laboratory experiment of Hennig-Schmidt et al. (2011). This setup identifies both physicians' profits and patients' health benefit resulting from medical treatment decisions. It estimates a random utility model applying multinomial logit regression, finding that physicians attach a positive weight on patients' health benefit. Furthermore, physicians vary substantially in their degree of altruism. Finally, we provide some implications for the design of physician payment schemes.

Diagnoses-based risk adjustment in the German remuneration system for outpatient medical care.
Ajustement du risque axée sur les diagnostics dans le système allemand de rémunération des soins ambulatoires.

Walendzik A.
Essen : Institut für Betriebswirtschaft und Volkswirtschaft. (I.B.E.S.). : 2011/11 : 109 p.

In Germany as in most countries, risk adjustment up to now has mainly been used between health funds. The aim is to avoid risk selection in order to use competition of health funds to improve efficiency and effectiveness in health care. As a recent development, in 2009 - together with the introduction of the German Health Fund - a morbidity based risk adjustment scheme to distribute resources between the about 180 competing social health funds has been installed. But in the same year, the reform of the remuneration system of physicians in outpatient care depicted a second field of implementation of risk adjustment in the German social health care system introducing some forms of risk adjustment in this context as well. Changes in morbidity of the patient population have to be measured since then and, fulfilling a long-term claim of physicians, morbidity risk was transferred from physicians to statutory health funds. As legal regulations of the reform left space for interpretation, discussions about purposes and potential implementation fields of risk adjustment in the remuneration system for outpatient medical care have been triggered. An important question from an economic point of view is Can the remuneration system for outpatient medical care in Germany be improved by including risk adjustment? This dissertation tries to enrich the discussion about the role of risk adjustment in the German outpatient remuneration system by providing new methodological solutions in the use of a diagnoses based classification system as well as an analysis of the conditions for their use under the specific German conditions.

Comparative analysis of delivery of primary eye care in three European countries.
Analyse comparative de l'offre de soins optiques dans trois pays européens.

Thomas D., Weegen L., Walendzik A.
Essen : Institut für Betriebswirtschaft und Volkswirtschaft. (I.B.E.S.). : 2011 : 257 p.

The organisation of primary eye care services in Europe is not uniform. While in some countries primary eye care is exclusively within the scope of practice of ophthalmologists, other systems rely on a variety of different professions providing essential parts of primary eye and vision health care. The study at hand addresses the question whether costs and outcomes of primary eye care services differ between heterogeneously organised systems. Therefore a special focus on the participation of opticians and optometrists was set. Having similar populations and economic conditions, but differently organised eye care systems, the countries France, Germany and the UK were exemplarily analysed as target countries. Based on an initial description of the different primary eye care systems, a criteria-based evaluation of costs and outcomes was conducted. Information was gained by expert-interviews and a systematic literature search in the Scorpus database alongside with unsystematic Internet searches.

Statistic

Avoiding disclosure of individually identifiable health information: a literature review.
Eviter la divulgation des données de santé individuelles : une revue de la littérature.

Prada S.I., Gonzalez C., Borton J. et al.
Munich : Munich Personal RepEc Archive : 2011/12 : 16 p.

Achieving data and information dissemination without arming anyone is a central task of any entity in charge of collecting data. This article examines the literature on data and statistical confidentiality. Rather than comparing the theoretical properties of specific methods, they emphasize the main themes that emerge from the ongoing discussion among scientists regarding how best to achieve the appropriate balance between data protection, data utility, and data dissemination. They cover the literature on de-identification and rei-dentification methods with emphasis on health care data. The authors also discuss the benefits and limitations for the most common access methods. Although there is abundant theoretical and empirical research, their review reveals lack of consensus on fundamental questions for empirical practice: How to assess disclosure risk, how to choose among disclosure methods, how to assess reidentification risk, and how to measure utility loss.

Foreign Health Care System

Health Reform, Health Insurance, and Selection: Estimating Selection into Health Insurance Using the Massachusetts Health Reform.
Réforme de la santé, assurance maladie et sélection : estimation de la sélection en assurance-santé, à l'aide de la réforme de la santé dans le Massachusetts.

Hackmann M.B., Kolstad J.T., Kowalski A.E.
Cambridge : NBER : 2012/01 : 6 p.

This paper implements an empirical test for selection into health insurance using changes in coverage induced by the introduction of mandated health insurance in Massachusetts. Our test examines changes in the cost of the newly insured relative to those who were insured prior to the reform. We find that counties with larger increases in insurance coverage over the reform period face the smallest increase in average hospital costs for the insured population, consistent with adverse selection into insurance before the reform. Additional results, incorporating cross-state variation and data on health measures, provide further evidence for adverse selection.

Work and Health

Active ageing and gender equality: A labour market perspective.
Vieillissement actif et égalité des sexes : perspective du point de vue du marché du travail.

Botti F., Corsi M., D'Ippoliti C.
Bruxelles : Université libre de Bruxelles : 2011 : 23 p.

Active ageing strategies have so far strongly focused on increasing senior workers employment rates through pension reforms to develop incentives to retire later on the one hand, and labour market policies on the other hand. Most measures are based on the dominant male trajectory of work and retirement and they are not explicitly gender mainstreamed. By contrast, a gender approach would prove fundamental to the labour market inclusion of elderly people, because in old age women suffer from the accumulated impact of the barriers to employment they encountered during their lifetime (e.g., repeated career breaks, part-time work, low pay and gender pay gap). Moreover, it appears that some pension reforms, by mandating a higher postponement of retirement and by establishing tighter links between formal employment and pension benefits may negatively affect the already high risk of poverty for elderly women.

Socioeconomic Heterogeneity in the Effect of Health Shocks on Earnings. Evidence from Population-Wide Data on Swedish Workers.
L'hétérogénéité socio-économique dans l'effet des chocs de santé sur les salaires. Résultats issus de données à l'échelle de la population des travailleurs suédois.

Lundborg P., Nilsson M., Vikstrom J.
Uppsala : Uppsala Center for Labor Studies : 2011 : 42 p.

This paper estimates socioeconomic heterogeneity in the effect of unexpected health shocks on labor market outcomes, using register-based data on the entire population of Swedish workers. It effectively exploits a Difference-in-Difference-in-Differences design, in which it compares the change in labor earnings across treated and control groups with high and low education levels. If the anticipation effects are similar for individuals with high and low education, any difference in the estimates across socioeconomic groups could plausibly be given a causal interpretation. The results suggest a large amount of heterogeneity in the effects, in which individuals with a low education level suer relatively more from a given health shock. These results hold across a wide range of different types of health shocks and become more pronounced with age. The results suggest that socioeconomic heterogeneity in the effect of health shocks offers one explanation for how the socioeconomic gradient in health arises.

SELECTED FOR YOU... FEBRUARY 2012: books of the month site of the month working papers