Exploring the determinants of private healthcare providers' market power: A performance-based perspective.

This research focuses on market power in the private healthcare sector. This topic has been poorly explored by the extant literature and the reasons mainly rely on the peculiarities of the sector and the specific market. In fact, health providers' market power is influenced by multiple factors and by the fact that prices are often regulated by national or regional public authorities. To fill this gap, the article explores the relationship between performance characteristics and health providers' market power, measured through the Lerner index. The research is based on the analysis of panel data for 437 Italian private healthcare providers over the period 2012-2020. To explore the determinants of health providers' market power, this research employs System-generalized method of moments (SYS-GMM) estimation models. The results highlight a significant and non-linear relationship between market power and process performance, as well as with gender diversity. Intangible assets are another input variable that has a significant and positive relationship with market power. The study contributes to the identification of the performance characteristics driving health providers' market power.

A Pragmatic and Systemic Approach to Advance Research in Health Policy and Management Comment on "Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research".

"Healthcare is complex" - or similar sentences - is a statement that introduces a wide number of scientific articles dealing with health policy and management issues. We all agree that healthcare is complex, but most studies, although using this kind of sentence to introduce their background, do little to effectively deal with such complexity in their analyses. Holmström et al proposed a methodological approach to tackle healthcare complexity by integrating system dynamics (SD) into action research (AR). This commentary highlights three touch points that makes the combination of AR and SD feasible, namely the epistemological ground, the use of experimentation and the collaborative approach. The proposed approach addresses some of the key sources of the complexity characterizing healthcare settings.

The Challenges of Hospitals' Planning & Control Systems: The Path toward Public Value Management.

In the last decades, public management has been subjected to a shift from the New Public Management (NPM) paradigm to the Public Value Management (PVM) one. Thus, management practices such as Planning and Control (P&C) systems have been called to evolve accordingly. The health care sector has not escaped this process. This paper focuses on the evolution of hospitals' P&C systems to support the paradigm shift from the NPM paradigm to the PVM one. In particular, the paper aims at exploring whether hospitals' P&C systems in Italy evolved, or are evolving, consistently with PVM and what are the expected benefits related to such a paradigm switch. To address the research aim, the paper is based on a review of scientific and grey literature and the case study of the diabetic-foot pathway in an Italian Regional Healthcare System. The results of this study show that the current P&C systems in Italian hospitals are not yet designed to support the shift toward the PVM approach and are still mainly focused on financial aspects and intra-organizational dynamics. Combining traditional P&Cs with performance measures assessing the system's outcomes may support hospitals in aligning their goals with the health system they are operating within and, therefore, P&C systems may represent an important driving force toward change. Such results provide suggestions for both practitioners and academics on how to adapt P&C systems to better support the implementation of current strategies of the public sector.

What is the performance in public hospitals? A longitudinal analysis of performance plans through topic modeling.

BACKGROUND: Both the concept of performance and the role of hospitals in health systems evolved significantly in the last decades. Today, the performance in health could be defined as the ability to create 'population value,' and the hospitals' role is to support this aim by providing acute care and by integrating and coordinating their activity with other settings of care. This research aims to assess how and with what degree the management of public hospitals have embraced in practice the updated concept of performance and their new role. RESULT: The paper analyses 181 performance plans of 48 Italian autonomous public hospitals over a nine-year period through the topic modeling algorithm called Latent Dirichlet Allocation (LDA). This is a method that allows for analysing large textual corpora that generates a representation of the latent topics discussed therein. The concept of performance in public hospitals was framed into 15 topics resulting from the analysis of the hospitals' performance plans. The prevalence of each topic was analysed through the period considered so as to understand the evolution of performance-related practices over the last decade. CONCLUSION: In recent years, the concept of performance in hospitals evolved toward the adoption of an outcome-based and population-based perspective. Additional effort should be devoted toward improved collaboration and integration of care with other settings.

Healthy Living and Co-Production: Evaluation of Processes and Outcomes of a Health Promotion Initiative Co-Produced with Adolescents.

Co-production is an approach to designing, delivering, and evaluating public services through strict collaboration among professionals and the people using services with an equal and reciprocal relationship. Health promotion initiatives that include education services rarely use the co-production approach. Nevertheless, the value of co-production is widely recognized, although it is considered a normative good, and scarce and mixed evidence is available in literature. The purpose of this paper is to provide evidence supporting the hypothesis that a co-production approach, applied to an intervention for preventing obesity, can be effective and efficient. To this end, an evaluation of the processes, outputs meant as intermediate results, and behavioral and economic outcomes of a public health-promotion initiative co-produced and co-delivered with adolescents (beFood) was conducted. Mixed methods were used, including field-observations, two self-reported questionnaires, and an opportunity-cost analysis that compared beFood to traditional approaches of public health promotion. The co-production model was successfully implemented and appears to be effective-more than 5000 adolescents were reached by only 49 co-producer adolescents, who reported behavioral changes (e.g., eating better and practicing more physical activity). The cost analysis showed that the co-production approach was also efficient, producing relevant savings and potentially making available more than 3000 h of professionals' time. This research can support a re-thinking of public institutions' organization, public initiatives' design, and public servants' role.

A Performance Management System in Healthcare for All Seasons?

Health systems face challenges which are inherent to care demand and supply evolution (i.e., demographic change, new technologies) or are the results of unexpected occurrence originating outside the health system, such as economic shocks or epidemic outbreaks. Both challenges often require a paradigm shift in governance and organization, financing and resource allocation, accountability frameworks, as well as public health system responses. Based on key reviews and seminal papers of performance management, public health, sustainability and resilience, the article presents three emerging challenges for performance management systems in healthcare: i) the inclusion of the population approach; ii) the measurement and consideration of the multi-facets concepts of value; iii) the importance of resilience and sustainability. Performance management systems need to evolve to cope with this changing scenario. The article sheds light on uncovered areas by performance management, and it proposes a research agenda for scholars of both performance management and health service research.

Measuring the quality of care in small countries: the empirical analysis of 30-day mortality following acute myocardial infarction and ischaemic stroke in Latvia.

The evaluation of quality of care is a complex task that, over the last decades, has been performed using the Donabedian model as its main conceptual framework. Small countries are an ideal setting in which to make innovative, empirical evaluations of the quality of care. In this research, we discussed the challenges and opportunities of assessing hospital performance in Latvia, a small country in the Baltic region of Northern Europe. The study outcomes were 30-day acute myocardial infarction mortality and 30-day ischaemic stroke mortality. We described how indicator specifications, risk-adjustment, data reliability assessment and graphical representations were tailored to the geographic and institutional context of Latvia. By looking at the impact of structural characteristics on hospital performance, we found that cath labs and large caseloads were significantly associated with lower mortality. This approach allows decision-makers at different governance levels to design and implement actions aimed at improving the quality of care. At the health system level, it may help policy-makers adopt proper strategies to tackle poor outcomes; at the hospital level, it may help managers intervene on structural determinants of performance. Because small countries face some relevant issues that have implications for health care, these analyses might be relevant also for larger countries to improve the design of their health-care services.

Unintended consequences of expenditure targets on resource allocation in health systems.

In recent decades, several countries have reformed their health care systems leading to the devolution of power to a lower governance level and, subsequently, to re-centralisation. Due to the ambiguous results of these policies and the start of the financial crisis of 2008, a wide number of national governments implemented cutback initiatives aimed at controlling health expenditure. The literature shows that the introduction of such initiatives may have produced unintended consequences on health systems' performance. In order to better understand the power relations and the resulting decision-making processes between national governments and local authorities, it is important to focus on the effects of such expenditure control mechanisms on the inputs of the health systems, i.e. the production factors. This research aims at investigating the effects of a cutback initiative intended to control personnel costs in a federal Beveridge health system through the analysis of resource allocation at the devolved level. The paper is based on a quantitative analysis of data resulting from the financial statements published by the 21 Italian regional health systems from 2012 to 2017. The results show that, although the Italian regional health systems managed to reduce personnel costs - i.e. hitting the target - the control of the total cost dynamic was not fully addressed. Overall, the initiative implemented by the national government had the effect of limiting the decision-making autonomy of regional authorities, pushing them toward shifting resource allocation from personnel to the purchase of services.

Health system performance assessment in small countries: The case study of Latvia.

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision-making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence-based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness. Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks. Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country. As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.