Econ Papers Daily / 期刊论文
意大利国家卫生服务体系中地方卫生当局的整合与死亡率
Consolidation of Local Health Authorities and mortality in the Italian NHS
摘要
This paper studies the health consequences of administrative centralization in healthcare, focusing on the consolidation of Local Health Authorities (LHAs) within the Italian National Health Service. This type of reform fits within a broader set of cost-containment efforts aimed at reducing administrative expenditures and exploiting economies of scale. In the Italian case, the reform centralized governance and expanded the scale of health administration, creating authorities with substantially larger catchment areas and shifting decision-making to more heterogeneous jurisdictions. Such changes may affect the responsiveness of healthcare provision to local needs, the coordination of service delivery, and access to care. Using an event-study Difference-in-Differences design, we estimate the policy's impact on municipal mortality rates, accounting for heterogeneous treatment effects and co-occurring fiscal adjustment policies. We find a significant increase in mortality starting four years after implementation, with an average treatment effect on the treated of 2.1%. The effects are concentrated in municipalities belonging to absorbed LHAs and in those exposed to mergers involving relatively large pre-reform LHAs and substantial post-merger expansions in catchment areas; they are also unevenly distributed, creating new vulnerable areas. Welfare estimates based on life-years lost indicate that the monetary costs of increased mortality exceed plausible administrative savings by roughly an order of magnitude.
中文摘要
本文研究了医疗行政集权对健康结果的影响，重点关注意大利国家卫生服务体系中地方卫生机构（LHAs）的合并。此类改革属于旨在削减行政开支并利用规模经济的一系列成本控制措施的一部分。在意大利案例中，改革集中了治理权并扩大了卫生行政的规模，形成了覆盖区域显著扩大且决策权转向更具异质性辖区的机构。这些变化可能影响医疗服务对地方需求的响应性、服务提供的协调性以及医疗服务的可及性。利用事件研究双重差分设计，我们评估了该政策对市级死亡率的影响，并考虑了处理效应的异质性及同时实施的财政调整政策。我们发现，政策实施四年后死亡率显著上升，处理组的平均处理效应为2.1%。这一效应集中于被吸收合并的地方卫生机构所在市镇，以及涉及合并前规模相对较大且合并后覆盖区域大幅扩张的地方卫生机构的市镇；同时，该效应分布不均，催生了新的脆弱区域。基于生命年损失的福利估算表明，死亡率上升带来的货币成本大约超过合理的行政节省一个数量级。