Delving into public-expenditure elasticity: Evidence from a National Health Service acute-care hospital network.

INTRODUCTION: The sustainability of public hospital financing in Spain is a recurring issue, given its representativeness in annual public healthcare budgets which must adapt to the macroeconomic challenges that influence the evolution of spending. Knowing whether the responsiveness of hospital expenditure to its determinants (need, utilisation, and quasi-prices) varies according to the type of hospital could help better design strategies aimed at optimising performance. METHODS: Using SARIMAX models, we dynamically assess unique nationwide monthly activity data over a 14-year period from 274 acute-care hospitals in the Spanish National Health Service network, clustering these providers according to the average severity of the episodes treated. RESULTS: All groups showed seasonal patterns and increasing trends in the evolution of expenditure. The fourth quartile of hospitals, treating the most severe episodes and accounting for more than 50% of expenditure, is the most sensitive to quasi-price factors, particularly the number of beds per hospital. Meanwhile, the first quartile of hospitals, which treat the least severe episodes and account for 10% of expenditure, is most sensitive to quantity factors, for which expenditure showed an elasticity above one, while factors of production were not affected. CONCLUSIONS: Belonging to one or another cluster of hospitals means that the determinants of expenditure have a different impact and intensity. The system should focus on these differences in order to optimally modulate expenditure not only according to the needs of the population, but also according to the macroeconomic situation, while leaving hospitals room for manoeuvre in case of unforeseen events. The findings suggest strengthening a network of smaller hospitals (Group 1)-closer to their reference population, focused on managing and responding to chronicity and stabilising acute events-prior to transfer to tertiary hospitals (Group 4)-larger but appropriately sized, specialising in solving acute and complex health problems-when needed.

Revisiting systematic geographical variations in tonsils surgery in children in the Spanish National Health System: spatiotemporal ecological study on hospital administrative data.

OBJECTIVE: To provide new evidence on how tonsils surgery in children has geographically varied over time in the context of the Spanish National Health System. DESIGN: Observational ecological spatiotemporal study on geographical variations in medical practice, using linked administrative datasets, including virtually all surgeries performed from 2003 to 2015. SETTING: The Spanish National Health System, a quasi-federal structure with 17 autonomous communities (ACs), and 203 healthcare areas (HCAs). PARTICIPANTS: Patients aged 19 and younger residing in the HCAs and ACs. INTERVENTIONS: Tonsillectomy with adenoidectomy (T&A); and tonsillectomies alone (T). MAIN ENDPOINTS: (1) Evolution of T&A and T rates; (2) spatiotemporal variation in the risk of receiving T&A or T surgery at regional level (ACs) and HCAs; and (3) the fraction of the variation (FV) attributed to each of the components of variation-ACs, HCAs, year and interaction ACs year. RESULTS: T&A age-sex standardised rates increased over the period of analysis from 15.2 to 20.9 (5.7 points per 10 000 inhabitants). T alone remained relatively lower than T&A rates, evolving from 3.6 in 2003 to 3.9 in 2015 (0.3 points per 10 000 inhabitants). Most of the risk variation was captured at the HCAs level in both procedures (FV: 55.3% in T&A and 72.5% in T). The ACs level explained 27.6% of the FV in the risk in T&A versus 8% in T. The interaction ACs year was similar in both procedures (FV: 15.5% in T&A and 17.5% in T). The average trend hardly explained 1.46% and 1.83% of the variation, respectively. CONCLUSION: Our study showed wide persistent variations with a steady increase in rates and risk of T&A and a stagnation of T alone, where most of the variation risk was explained at HCA level.

¿Se puede permitir la gente pagar por la atención sanitaria? Nueva evidencia sobre la protección financiera en España

Este estudio forma parte de una serie de informes nacionales que han generado nueva evidencia sobre la protección financiera en los sistemas sanitarios europeos. La protección financiera es fundamental para la cobertura sanitaria universal y es una dimensión básica del desempeño de los sistemas sanitarios. A pesar de haber empeorado durante la crisis económica entre los años 2008 y 2014, la incidencia de los gastos catastróficos en salud en España es mucho menor de lo que cabría esperar dada la dependencia relativamente elevada de los pagos directos en España. Esto puede explicarse por los puntos fuertes de las políticas decobertura en el Sistema Nacional de Salud (SNS): cobertura sanitaria basada en la residencia, con la misma cobertura para los inmigrantes en situación no regularizada; una cartera de servicios completa en general; uso limitado de los copagos, y diferentes mecanismos para proteger a los usuarios de los copagos. Sin embargo, la cobertura presenta algunas deficiencias. Las causas principales del gasto catastrófico son la atención dental y los productos sanitarios en todos los quintiles de consumo, principalmente porque la atención dental y óptica están excluidas en gran medida de la cobertura del SNS. En el quintil más pobre, la causa del gasto catastrófico son los medicamentos de dispensación ambulatoria debidoa los copagos y a una protección inadecuada de los hogares de bajos ingresos con personas en edad de trabajar. Para reducir las necesidades insatisfechas y las dificultades financieras, las políticas deben centrarse en ampliar la cobertura del SNS para la atención dental y la atención óptica, así como seguir mejorando las modalidades de copago para reforzar la protección de los hogares más pobres en todos los grupos de edad.

Can people afford to pay for health care? New evidence on financial protection in Spain

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimensionof health system performance. Despite worsening during the economic crisis from 2008 to 2014, the incidence of catastrophic health spending in Spain is much lower than would be expected given Spain’s relatively heavy reliance on out-of-pocket payments. This can be explained by strengths in the design of coverage policy in the National Health System (NHS): entitlement to the NHS based on residence, with the same degree of entitlement for undocumented migrants; a generally comprehensive benefits package; limited use of co-payments; and multiple mechanisms to protect people from co-payments. There are gaps in coverage, however. Catastrophic spending is driven by dental care and medical products in all consumption quintiles, mainly because dental and optical care for eyesight problems are largely excluded from NHS coverage. Catastrophic spending in the poorest quintile is also driven by outpatient medicines, reflecting co-payments and inadequate protection for low-incomehouseholds of working age. To reduce unmet need and financial hardship, policy should focus on expanding NHS coverage of dental care and optical care and further improving the design of co-payments to strengthenprotection for poorer households in all age groups.

Factors underlying the growth of hospital expenditure in Spain in a period of unexpected economic shocks: A dynamic analysis on administrative data.

AIMS: We sought to understand the evolution of Spanish public hospital expenditure by assessing its elasticity to volume versus price, controlling for need and case severity, from January 2003 to December 2015, a period of unexpected economic shocks. METHOD: Observational study of administrative data characterising hospitals in the Spanish National Health System. Public hospital expenditure was modelled using SARIMAX in a two-step approach aiming at: a) eliciting structural changes in the monthly time-series; and, b) analysing the reaction of expenditure to the behaviour of its direct underlying factors over the sub-periods identified in the first step. RESULTS: From January 2003 to December 2015, two structural changes were elicited, splitting this time-span into three sub-periods. The quantities of hospital services offered (mainly inpatient medical and surgical activity) were consistently shown as the main drivers of expenditure. Overall, hospital expenditure was inelastic to all the factors analysed, specially to quasi-prices; similar results were obtained across sub-periods of analysis. CONCLUSION: Factors associated to quantities (as compared to quasi-prices) were the main drivers of hospital expenditure in the period analysed, particularly after the economic shock. However, hospital expenditure was inelastic to both factors giving prominence to the economic cycle fluctuations as a strong inducer of the hospital expenditure trends in Spain.

A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015.

BACKGROUND: Recently, the once archetype of the public private partnership (PPP) in the Spanish National Health System (SNHS), namely the Alzira's Model, has come to an end. Advocates defended the superiority of PPPs over public-tenured provision, in terms of quality and technical efficiency. This paper profiles and compares Alzira's life-cycle performance with similar public-tenured providers. METHODS: Observational study on secondary data from virtually all hospital care episodes produced in 51 integrated providers (i.e., administrative healthcare areas) and 67 hospitals, in 2003 and 2015. Alzira's 2015 performance (and its variation since 2003) was compared with all public-tenured peers in the SNHS, using 26 indicators analysing the differences in age-sex standardized rates of events or risk-adjusted mortality, severity-adjusted hospital expenditure and hospital technical efficiency. RESULTS: In comparison with the corresponding public-tenured peers, Alzira's 2015 performance was statistically worse than the benchmark in the majority of indicators (15 out of 26); yet, its performance was one of the best in the SNHS in adjusted-mortality after Percutaneous Coronary Intervention (PCI). Over time, Alzira showed a statistically greater 2003-2015 improvement than its peers' average in eleven of the indicators, and a lower improvement in nine. CONCLUSIONS: In this comprehensive comparative study on Alzira's performance, this PPP has not generally outperformed public-tenured providers, although in some areas of care its developments have been outstanding.

Evolution of public hospitals expenditure by healthcare area in the Spanish National Health System: the determinants to pay attention to.

BACKGROUND: In Spain, hospital expenditure represents the biggest share of overall public healthcare expenditure, the most important welfare system directly run by the Autonomous Communities (ACs). Since 2001, public healthcare expenditure has increased well above the GDP growth, and public hospital expenditure increased at an even faster rate. This paper aims at assessing the evolution of need-adjusted public hospital expenditure at healthcare area level (HCA) and its association with utilisation and 'price' factors, identifying the relative contribution of ACs, as the main locus of health policy decisions. METHODS: Ecological study on public hospital expenditure incurred in 198 (HCAs) in 16 Spanish ACs, between 2003 and 2015. Aggregated and annual log-log multilevel models, considering ACs as a cluster, were modelled using administrative data. HCA expenditure was analysed according to differences in population need, utilization and price factors. Standardised coefficients were also estimated, as well as the variance partition coefficients. RESULTS: Between 2003 and 2015, over 59 million hospital episodes were produced in Spain for an overall expenditure of €384,200 million. Need-adjusted public hospital expenditure, at HCA level, was mainly associated to medical and surgical hospitalizations (standardized coefficients 0.32 and 0.28, respectively). The ACs explained 42% of the variance not explained by HCA utilization and 'price' factors. CONCLUSIONS: Utilization, rather than 'price' factors, may be explaining the difference in need-adjusted public hospital expenditure at HCA level in Spain. ACs, third-payers in the fully devolved Spanish National Health System, are responsible for a great deal of the variation in hospital expenditure.