دانلود رایگان مقاله اقتصاد سیاسی گروه های مرتبط با تشخیص

abstract

A well-established political economic literature has shown as multi-level governance affects the inefficiency of public expenditures. Yet, this expectation has not been empirically tested on health expenditures. We provide a political economy interpretation of the variation in the prices of 6 obstetric DRGs using Italy as a case study. Italy offers a unique institutional setting since its 21 regional governments can decide whether to adopt the national DRG system or to adjust/waive it. We investigate whether the composition and characteristics of regional governments do matter for the average DRG level and, if so, why. To address both questions, we first use a panel fixed effects model exploiting the results of 66 elections between 2000 and 2013 (i.e., 294 obs) to estimate the link between DRGs and the composition and characteristics of regional governments. Second, we investigate these results exploiting the implementation of a budget constraint policy through a difference-in-differences framework. The incidence of physicians in the regional government explains the variation of DRGs with low technological intensity, such as normal newborn, but not of those with high technological intensity, as severely premature newborn. We also observe a decrease in the average levels of DRGs after the budget constraint implementation, but the magnitude of this decrease depends primarily on the presence of physicians among politicians and the political alignment between the regional and the national government. To understand which kind of role the relevance of the political components plays (i.e., waste vs. better defined DRGs), we check whether any of the considered political economy variables have a positive impact on the quality of regional obstetric systems finding no effect. These results are a first evidence that a system of standardized prices, such as the DRGs, is not immune to political pressures.

6. Conclusions

Using a unique dataset of 21 obstetric DRG tariffs in Italy, we test whether the characteristics of the regional governments that are responsible for approving these prices play any role in determining their levels. This research question is relevant because DRGs are fixed prices for health care treatments, and they were conceived to reduce discretion and inefficient expenditure within the health care sector. If DRGs are truly computed on the basis of hospital production function, then changes in the political economy variables should not have a direct effect on their average values. However, our analysis shows that the characteristics of the regional governments affect both average levels and compliance with a budget constraint policy. On average, the proportion of politicians in regional governments who are medical doctors plays an important role, especially for procedures that are more frequent and are less technologically complex. This seems to support the idea that politicians who are medical doctors tend to be more generous regarding the health care sector to increase support from their constituencies. Moreover, regarding the implementation of a budget constraint policy, such as a repayment plan, several of the political economy variables play a crucial role, including the share of medical doctors. The higher the share of medical doctors in the government, the weaker the commitment to undercut prices.

The use of patient discharge data also allows us to approximate the magnitude of the potential waste associated with our results. The analysis of the panel fixed effects model shows that a onestandard-deviation increase in the incidence of physicians on the regional council increases the DRG for vaginal deliveries with complications by 3%, the DRG for vaginal deliveries without complications by 4.7%, and the DRG for normal newborns by 4.9% at the mean of each variable. Although we are aware that these are imperfect proxies, we find no effect on the quality measures. Therefore the above effect seem to be associated with expenditures increases with no welfare gains. Given both the frequency and the average DRG price for these procedures/diagnoses in the period 2000e2013, the estimated increases correspond to additional expenditures of 8,373,429 euros (598,102 annually) for vaginal deliveries with complications, 328,153,980 euros (23,439,570 annually) for vaginal deliveries without complications, and 129,888,950 euros (9,277,782 annually) for normal newborns.