Quasi-market and cost-containment in Beveridge systems: The Lombardy model of Italy

Brenna, Elenka

doi:10.1016/j.healthpol.2011.10.003

Cited by 37 publications

(34 citation statements)

References 16 publications

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“…the management costs -as opposed to the total production cost is due to particular features of the Italian NHS that on the one hand expects the individual LHAs to keep within their budget and on the other makes the LHAs almost totally financially dependent on their Regional Governments financial transfers. 2 This makes it impossible to estimate economies of scale at an aggregate level. The potential total saving ( ij S ) which may derive from a pairwise consolidation of the LHAs i and j has been modelled as: 2 The Italian NHS organizational structure consists of three levels: central government: regions and autonomous provinces and local health authorities.…”

Section: The Merger Processmentioning

confidence: 99%

“…2 This makes it impossible to estimate economies of scale at an aggregate level. The potential total saving ( ij S ) which may derive from a pairwise consolidation of the LHAs i and j has been modelled as: 2 The Italian NHS organizational structure consists of three levels: central government: regions and autonomous provinces and local health authorities. The Central Government is responsible for the national health planning for ensuring the "essential levels of care" (Livelli Essenziali di Assistenza, LEA) to their citizens which guarantee equal health care coverage throughout the country (Torbica and Fattore, 2005).…”

Section: The Merger Processmentioning

confidence: 99%

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Larger is Better: The Scale Effects of the Italian Local Healthcare Authorities Amalgamation Program

2016

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C onsolidation is often considered as a m eans to low er service delivery costs and enhance accountability. T his paper uses a prospective evaluation design to derive estim ates of the potential cost savings that m ay arise from L ocal H ealthcare A uthorities (LH A s) am algam ation process, w hich is concerning the Italian N ational H ealth System . W e focus specifically on cost savings due to scale econom ies w ith reference to a particular subset of the production costs of the L H A s, i.e. the adm inistrative costs together w ith the purchasing costs of both goods as w ell as non -healthcare related services. O ur results dem onstrate the existence of econom ies of scale linked to the size of the LH A population. H ence, the decision to reduce the num ber of L H A s m ay result in larger local health authorities that are m ore cost efficient, especially w hen the consolidation process concerns m erging a large num ber of LH A . KeywordsItalian Health Care System, Local Health Authority, Consolidation AbstractConsolidation is often considered as a means to lower service delivery costs and enhance accountability. This paper uses a prospective evaluation design to derive estimates of the potential cost savings that may arise from Local Healthcare Authorities (LHAs) amalgamation process, which is concerning the Italian National Health System. We focus specifically on cost savings due to scale economies with reference to a particular subset of the production costs of the LHAs, i.e. the administrative costs together with the purchasing costs of both goods as well as non-healthcare related services. Our results demonstrate the existence of economies of scale linked to the size of the LHA population. Hence, the decision to reduce the number of LHAs may result in larger local health authorities that are more cost efficient, especially when the consolidation process concerns merging a large number of LHA.

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Section: The Merger Processmentioning

confidence: 99%

Section: The Merger Processmentioning

confidence: 99%

Larger is Better: The Scale Effects of the Italian Local Healthcare Authorities Amalgamation Program

2016

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“…The reform of the Italian NHS, which started in 1992 and was finalized in 1999, introduced competition principles among providers with the twofold objective of increasing the quality of care and containing the healthcare expenditure (23)(24)(25). The main features of the theoretical model are the separation between purchaser and provider, with competing providers, centrally set prospective prices [Diagnosis-Related Group (DRG) tariffs], the provision of greater and more accessible information on quality and the encouragement of entry, mainly from the private sector.…”

Section: Institutional Backgroundmentioning

confidence: 99%

Regional incentives and patient cross-border mobility: evidence from the Italian experience

Brenna

Spandonaro

2015

Int J Health Policy Manag

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Background: In recent years, accreditation of private hospitals followed by decentralisation of the Italian National Health Service (NHS) into 21 regional health systems has provided a good empirical ground for investigating the Tiebout principle of "voting with their feet". We examine the infra-regional trade-off between greater patient choice (due to an increase in hospital services supply) and financial equilibrium, and we relate it to the significant phenomenon of Cross-Border Mobility (CBM) between Italian regions. Focusing on the rules supervising the financial agreements between regional authorities and providers of hospital care, we find incentives for private accredited providers in attracting patient inflows. Methods: The analysis is undertaken from an institutional, regulatory and empirical perspective. We select a sample of five regions with higher positive CBM balance and we examine regional regulations governing the contractual agreements between purchasers and providers of hospital care. According to this sample, we provide a statistical analysis of CBM and apply a Regional Attraction Ability Index (RAAI), aimed at testing patient preferences for private/public accredited providers. Results: We find that this index is systematically higher for private providers, both in the case of distance/boundary patients and of excellence/general hospitals. Conclusion: Conclusions address both financial issues regarding the coverage of regional healthcare systems and equity issues on patient healthcare access. They also raise concerns on the new European Union (EU) directive inherent to patient mobility across Europe.

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“…277 Compared with the English NHS, the strength of this highly vertical system was its control over providers and its homogeneous way of gathering information and data, which has been described (p. 209) 276 as a 'quasi-administered' system. Nevertheless we found at regional level a considerable fragmentation of management, a 'silo' approach coupled with a lack of information sharing and of transparency in decision-making.…”

Section: Managerial Performancementioning

confidence: 99%

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Sheaff

Charles

Mahon

et al. 2015

Health Services and Delivery Research

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BackgroundBy 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).ObjectivesTo: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.DesignMixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.ResultsIn the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.ConclusionsCommissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Quasi-market and cost-containment in Beveridge systems: The Lombardy model of Italy

Cited by 37 publications

References 16 publications

Larger is Better: The Scale Effects of the Italian Local Healthcare Authorities Amalgamation Program

Larger is Better: The Scale Effects of the Italian Local Healthcare Authorities Amalgamation Program

Regional incentives and patient cross-border mobility: evidence from the Italian experience

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

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