Three essays in health economics

The present PhD Thesis titled “Three Assays on Health Economics” consists of three separates pieces of research on three different topics. The first paper is entitled “Do mergers affect hospital outputs and outcomes? Evidence from the English secondary care sector”. We analyze the impact of hospital mergers on several measures of hospital outputs and outcomes over the period 2000-2008 in order to understand whether English hospital Trusts that have merged are able to reconfigure their service offer more significantly than non-merged Trusts and consequently to achieve an advantage relative to non-merged Trusts. In order to answer this question, for the analysis on hospital outputs, we adopt an innovative flexible conditional difference-in-difference approach, developed by Dettman et al. (2020) able to capture mergers with varying start dates and varying treatment durations. Regarding the analysis on hospital outcomes, we adopt a fixed effect ordered logit model as developed by Dickerson et al. (2014). Our empirical analysis shows a negative impact of hospital mergers on both hospital outputs and outcomes. The second paper is entitled “Financial crisis, fiscal austerity, and health in Italy”. This paper aims to assess whether the economic crisis (2007-2008) and the Italian sovereign debt crisis (2010-2011) have both had any impact on the health of the Italian population, proxied by a wide set of indicators. Following previous papers by Kentikelenis (2015), Kentikelenis et al. (2014) and Karanikolos et al. (2013) we analyze the effect of regional bail-out plans adoption on a broad set of health status measures during the period 1999-2015 considering the bail-out effect on physical and psychological measures of health status, focus on social distress. We adopt a Variable Instrumental approach to address potential endogeneity issues associated with the choice of adopting bail-out plans. Our empirical results show a general increase in mortality rate, and also of the incidence of some infectious diseases. The adoption of bail-out plans affects mainly vulnerable people with psychological diseases. The third paper is entitled “Does co-payment exemption increase diagnostic care utilization? A causal approach for the Italian care system”. The purpose of this paper is to analyze the effect of co-payment exemption on the diagnostic care utilization. Increased utilization of healthcare can be driven either by health needs or by opportunistic behavior. In this preliminary analysis we overcome the potential endogeneity associated to co-payment exemption by adopting an Instrumental Variable approach. We consider the Global Competitiveness Index at regional level as the proxy of bureaucracy and administrative slowness. Our findings reveal a weakness of instrument due to weak joint statistical independence. In order to estimate the possible effect of co-payment on diagnostic cares utilization, we adopt an alternative empirical method based on the estimation of intersection bound. Preliminary findings confirm that co-payment exemption increase the average number of diagnostic care and also, reveal potential opportunist behavior. Even if our preliminary results cannot allow to estimate the exact effect of co-payment exemption, the inference on intersection bounds permits to identify the possible dimension of the issue.