Introduction
Background and hypotheses
Materials and methods
Policy impact analysis applied to drugs
Variables under consideration
Regions | Copayment | Prescription quotas | Therapeutic reference pricing | |||
---|---|---|---|---|---|---|
Years | Months of activation (number) | Years | Months of activation (number) | Years | Months of activation (number) | |
Piemonte | 2002–2014 | 151 | 0 | 0 | ||
Valle d’Aosta | 0 | 2006–2014 | 104 | 0 | ||
Lombardia | 2002–2014 | 143 | 0 | 0 | ||
PA Bolzano | 2002–2014 | 149 | 0 | 0 | ||
PA Trento | 0 | 0 | 0 | |||
Veneto | 2003–2014 | 139 | 0 | 0 | ||
Friuli Venezia Giulia | 0 | 0 | 0 | |||
Liguria | 2002–2014 | 144 | 2007–2014 | 94 | 2007–2014 | 94 |
Emilia Romagna | 2011–2014 | 38 | 0 | 0 | ||
Toscana | 2012–2014 | 26 | 2007–2014 | 93 | 0 | |
Umbria | 2011–2014 | 38 | 0 | 0 | ||
Marche | 0 | 2007–2014 | 93 | 0 | ||
Lazio | 2002–2005, 2008–2014 | 118 | 2007–2014 | 91 | 0 | |
Abruzzo | 2002–2014 | 149 | 2005–2014 | 113 | 2007–2014 | 94 |
Molise | 2002–2014 | 144 | 2008–2014 | 73 | 2007–2014 | 91 |
Campania | 2007–2014 | 94 | 2007–2014 | 88 | 2007–2014 | 88 |
Puglia | 2002–2014 | 147 | 0 | 2007–2014 | 94 | |
Basilicata | 2013–2014 | 16 | 2007–2014 | 90 | 2007–2014 | 90 |
Calabria | 2002–2005, 2009–2014 | 108 | 2012–2014 | 32 | 2007–2014 | 93 |
Sicilia | 2004–2014 | 124 | 2007–2014 | 91 | 2007–2014 | 91 |
Sardegna | 2002–2004 | 21 | 2012–2014 | 31 | 2007–2014 | 93 |
Variable | Measure | Source |
---|---|---|
Per capita public pharmaceutical expenditures (ln) | ln of per capita monthly public pharmaceutical expenditures | Pharmaceutical observatory, CERGAS Bocconi |
Per capita private pharmaceutical expenditures (ln) | ln of per capita monthly private pharmaceutical expenditures | Pharmaceutical observatory, CERGAS Bocconi |
Per capita volumes of reimbursed drugs (ln) | ln of per capita monthly volumes (units) sold of reimbursed drugs | Pharmaceutical observatory, CERGAS Bocconi |
Per capita volumes of nonreimbursed drugs (ln) | ln of per capita monthly volumes (units) sold of nonreimbursed drugs | Pharmaceutical observatory, CERGAS Bocconi |
Copayment, prescription quotas and TRP | Dummy variables: 1 if the policy is active in the region during a focal month | Pharmaceutical observatory, CERGAS Bocconi |
Region with turnaround plan | Dummy variable: 1 if a turnaround plan is active in the region during a focal month | Ministry of Health and OASI observatory |
Average monthly income (×1000 euros) | Total regional monthly income per capita measured in 1000 euros (derived by a proportion of the annual income) | IISTAT |
Share of >65-year-olds | Percentage of population >65 years (yearly average) | ISTAT |
Share of <14 year-olds | Percentage of population <14 years (yearly average) | ISTAT |
Number of regions with copayment | Number of regions, excluding the focal one, that have already introduced copayment policies during a focal month | Pharmaceutical observatory, CERGAS Bocconi |
Left-leaning regional government | Dummy variable: 1 if the region has a left-leaning government during a focal month | Ministry of Internal Affairs |
Pre-electoral period | Dummy variable: 1 if an election for the regional government occurs within 3 months from the focal month | Ministry of Internal Affairs |
Observations | 3423 | |
Number of regions and autonomous provinces | 21 |
The model
Results
DD models for individual and interactive effects
Copayment only | Copayment + control variables | All three policies + control variables | |
---|---|---|---|
Table 4a (expenditures) | Models 1 and 4 | Models 2 and 5 | Models 3 and 6 |
Table 4b (volumes) | Models 7 and 10 | Models 8 and 11 | Models 9 and 12 |
Variable | Mean | Standard deviation | Max | Min |
---|---|---|---|---|
Per capita public pharmaceutical expenditures (€) | 15.63 | 3.02 | 28.10 | 7.48 |
Per capita private pharmaceutical expenditures (€) | 9.73 | 2.38 | 20.11 | 2.32 |
Per capita volumes of reimbursed drugs (units) | 1.57 | 0.28 | 3.15 | 0.83 |
Per capita volumes of nonreimbursed drugs (U) | 0.85 | 0.17 | 1.43 | 0.50 |
Per capita public pharmaceutical expenditures | 2.73 | 0.20 | 3.34 | 2.01 |
Per capita private pharmaceutical expenditures (ln) | 2.24 | 0.26 | 3.00 | 0.84 |
Per capita volumes of reimbursed drugs (ln) | 0.43 | 0.18 | 1.15 | −0.19 |
Per capita volumes of nonreimbursed drugs (ln) | −0.18 | 0.20 | 0.36 | −0.70 |
Copayment | 0.50 | 0.50 | 1.00 | 0.00 |
Prescription quotas | 0.28 | 0.45 | 1.00 | 0.00 |
TRP | 0.24 | 0.43 | 1.00 | 0.00 |
Turnaround | 0.21 | 0.40 | 1.00 | 0.00 |
Average monthly income (×1000 euros) | 2.06 | 0.52 | 3.22 | 1.12 |
Share of >65 years | 12.41 | 9.21 | 26.00 | 0.15 |
Share of <14 years | 8.53 | 6.32 | 18.75 | 0.11 |
Number of regions with copayment | 10.54 | 4.06 | 16.00 | 0.00 |
Left-leaning regional government | 0.57 | 0.49 | 1.00 | 0.00 |
Pre-electoral period | 0.05 | 0.22 | 1.00 | 0.00 |
Variables | (1) | (2) | (3) | (4) | (5) | (6) |
---|---|---|---|---|---|---|
Public expenditures | Public expenditures | Public expenditures | Private expenditures | Private expenditures | Private expenditures | |
(a) | ||||||
Copayment | −0.136*** | −0.069*** | −0.060*** | 0.103*** | 0.079*** | 0.090*** |
Copayment (>6 m) | −0.060*** | 0.011* | 0.014** | 0.135*** | −0.017* | −0.016 |
Prescription quotas | 0.001 | 0.061*** | ||||
Prescription quotas (>6 m) | −0.018** | 0.003 | ||||
TRP | −0.013 | 0.024 | ||||
TRP (> 6 m) | 0.037*** | 0.069*** | ||||
Copayment × prescription quotas | −0.049*** | −0.009 | ||||
Copayment × TRP | 0.007 | −0.040*** | ||||
Prescription quotas × TRP | 0.019** | −0.021* | ||||
R (copayment) | 0.205*** | −0.038 | 0.014 | −0.149 | −0.029 | 0.039 |
R (prescription quotas) | 0.092 | 0.032 | ||||
R (TRP) | −0.307*** | −0.425*** | ||||
T (copayment) | 0.004 | 0.230 | 0.350* | 0.193*** | 0.140 | 0.207 |
T (prescription quotas) | −0.126*** | −0.080 | ||||
T (TRP) | 0.191 | 0.238 | ||||
Region with turnaround plan | −0.022*** | −0.014*** | 0.002 | −0.015** | ||
R (turnaround) | 0.043 | 0.180*** | −0.157** | 0.098** | ||
T (turnaround) | 0.191 | – | 0.122 | |||
Average monthly income (×1000) | −0.313*** | −0.336*** | −0.195*** | −0.176*** | ||
Share of >65 year | 0.009*** | 0.008*** | 0.012*** | 0.015*** | ||
Share of <14 year | 0.009*** | 0.011*** | −0.033*** | −0.025*** | ||
Number of regions with copayment | −0.017 | −0.015 | −0.001 | −0.001 | ||
Left-leaning regional government | −0.000 | 0.002 | −0.035*** | −0.028*** | ||
Pre-electoral period | −0.005 | −0.005 | 0.009 | 0.010 | ||
Monthly and quarterly dummy variables | No | Yes | Yes | No | Yes | Yes |
Constant | 2.657*** | 3.105*** | 3.106*** | 2.069*** | 2.740*** | 2.515*** |
Observations | 3486 | 3423 | 3423 | 3486 | 3423 | 3423 |
Number of regions | 21 | 21 | 21 | 21 | 21 | 21 |
R
2 (overall) | 0.104 | 0.662 | 0.753 | 0.160 | 0.416 | 0.674 |
R
2 (within) | 0.191 | 0.869 | 0.875 | 0.285 | 0.833 | 0.842 |
R
2 (between) | 0.038 | 0.511 | 0.633 | 0.009 | 0.032 | 0.368 |
χ
2
| 814.1 | 21,242 | 22,583 | 1377 | 15,907 | 17,030 |
p value (χ
2) | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 |
Variables | (7) | (8) | (9) | (10) | (11) | (12) |
---|---|---|---|---|---|---|
Class-A units | Class-A units | Class-A units | Other classes | Other classes | Other classes | |
(b) | ||||||
Co-payment | −0.038*** | −0.033*** | −0.018*** | −0.009 | −0.002 | 0.007 |
Co-payment (>6 m) | 0.169*** | 0.004 | 0.009 | −0.076*** | −0.001 | −0.002 |
Prescription quotas | 0.022*** | 0.004 | ||||
Prescription quotas (>6 m) | −0.005 | 0.002 | ||||
TRP | 0.025** | 0.055*** | ||||
TRP (>6 m) | 0.034*** | 0.016* | ||||
Co-payment × Prescription quotas | −0.046*** | 0.005 | ||||
Co-payment × TRP | −0.032*** | −0.036*** | ||||
Prescription quotas × TRP | 0.014* | −0.003 | ||||
R (co-payment) | 0.003 | 0.016 | 0.056 | −0.040 | −0.050 | −0.004 |
R (prescription quotas) | 0.097*** | 0.055 | ||||
R (TRP) | −0.196*** | −0.279*** | ||||
T (co-payment) | −0.001 | −0.195 | −0.219 | −0.152*** | 0.152 | 0.462*** |
T (prescription quotas) | −0.002 | −0.321*** | ||||
T (TRP) | 0.007 | 0.199* | ||||
Region with turnaround plan | −0.006 | −0.000 | 0.002 | −0.007* | ||
R (turnaround) | 0.019 | 0.096** | −0.058 | 0.099** | ||
T (turnaround) | 0.014 | – | 0.125 | |||
Average monthly income (×1000) | −0.183*** | −0.171*** | 0.005 | 0.029 | ||
Share of >65 year | 0.001 | 0.001 | 0.000 | 0.002* | ||
Share of <14 year | −0.012*** | −0.009*** | −0.016*** | −0.011*** | ||
Number of regions with co-payment | 0.022 | 0.024 | −0.046*** | −0.046*** | ||
Left-leaning regional government | 0.001 | 0.008** | 0.001 | 0.007** | ||
Pre-electoral period | −0.001 | −0.000 | −0.008* | −0.008* | ||
Monthly and quaterly dummy variables | No | Yes | Yes | No | Yes | Yes |
Constant | 0.365*** | 0.817*** | 0.727*** | 0.049 | 0.276*** | 0.108 |
Observations | 3234 | 3171 | 3171 | 3234 | 3171 | 3171 |
Number of regions | 21 | 21 | 21 | 21 | 21 | 21 |
R
2 (overall) | 0.030 | 0.663 | 0.748 | 0.049 | 0.442 | 0.642 |
R
2 (within) | 0.105 | 0.863 | 0.871 | 0.066 | 0.845 | 0.854 |
R
2 (between) | 0.001 | 0.397 | 0.568 | 0.041 | 0.227 | 0.521 |
χ
2
| 370.4 | 18,755 | 20,043 | 228.7 | 16,256 | 17,232 |
p value (χ
2) | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 | 0.000 |
Effects on public expenditures
Effects on volumes
Effects on patient expenditures
Test of a mediation by behavioural mechanisms
Independent variable | Mediator | Support for mediation hypthesis | Effect mediated | Direct effect on public expenditures | Indirect effect on public expenditures | Total effect on public expenditures | Sobel–Goodman test (p value) |
---|---|---|---|---|---|---|---|
Cost sharing | Volumes | Yes | 59.7 % | −3.0 % | −4.4 % | −7.4 % | <0.01 |
Private expenditures | Yes | 26.5 % | −3.0 % | −1.1 % | −4.1 % | <0.01 | |
Prescription quotas | Volumes | Yes (only indirect effect) | 161.0 % | NS | 2.0 % | NS | <0.05 |
Private expenditures | No | 35.5 % | NS | NS | NS | >0.05 | |
TRP | Volumes | No | NS | NS | NS | NS | >0.05 |
Volumes (in the long run) | Yes | −152.2 % | 3.6 % | −2.2 % | NS | <0.01 | |
Private expenditures | No | NS | NS | NS | NS | >0.1 |
Effects | Coefficient | Standard error |
Z
| Significance | Bootstrap coefficient | |
---|---|---|---|---|---|---|
DV: public expentitures; IV: cost sharing; MV: volumes | ||||||
Sobel | −0.044 | 0.007 | −6.453 | *** | ||
Goodman-1 (Aroian) | −0.044 | 0.007 | −6.452 | *** | ||
Goodman-2 | −0.044 | 0.007 | −6.454 | *** | ||
a coefficient | −0.055 | 0.008 | −6.495 | *** | ||
b coefficient | 0.810 | 0.014 | 56.677 | *** | ||
Indirect effect | −0.044 | 0.007 | −6.453 | *** | −0.044 | |
Direct effect | −0.030 | 0.007 | −4.504 | *** | −0.030 | |
Total effect | −0.074 | 0.010 | −7.823 | *** | −0.074 | |
Proportion of total effect mediated | 59.7 % | |||||
Ratio of indirect to direct effect | 1.482 | |||||
Ratio of total to direct effect | 2.482 | |||||
DV: public expentitures; IV: cost sharing; MV: private expenditures | ||||||
Sobel | −0.011 | 0.002 | −5.342 | *** | ||
Goodman-1 (Aroian) | −0.011 | 0.002 | −5.333 | *** | ||
Goodman-2 | −0.011 | 0.002 | −5.352 | *** | ||
Coefficienta
| 0.076 | 0.013 | 5.679 | *** | ||
Coefficientb
| −0.143 | 0.009 | −15.742 | *** | ||
Indirect effect | −0.011 | 0.002 | −5.342 | *** | −0.011 | |
Direct effect | −0.030 | 0.007 | −4.504 | *** | −0.030 | |
Total effect | −0.041 | 0.007 | −5.922 | *** | −0.041 | |
Proportion of total effect mediated | 26.5 % | |||||
Ratio of indirect to direct effect | 0.360 | |||||
Ratio of total to direct effect | 1.360 | |||||
DV: public expentitures; IV: prescription quotas; MV: volumes | ||||||
Sobel | 0.020 | 0.009 | 2.231 | ** | ||
Goodman-1 (Aroian) | 0.020 | 0.009 | 2.23 | ** | ||
Goodman-2 | 0.020 | 0.009 | 2.231 | ** | ||
Coefficienta
| 0.025 | 0.011 | 2.232 | ** | ||
Coefficientb
| 0.810 | 0.014 | 56.677 | *** | ||
Indirect effect | 0.020 | 0.009 | 2.231 | ** | 0.020 | |
Direct effect | −0.008 | 0.009 | −0.874 | −0.008 | ||
Total effect | 0.012 | 0.012 | 0.997 | 0.012 | ||
Proportion of total effect mediated | 161.0 % | |||||
Ratio of indirect to direct effect | −2.639 | |||||
Ratio of total to direct effect | −1.639 | |||||
DV: public expentitures; IV: prescription quotas; MV: private expenditures | ||||||
Sobel | −0.004 | 0.002 | −1.665 | * | ||
Goodman-1 (Aroian) | −0.004 | 0.002 | −1.661 | * | ||
Goodman-2 | −0.004 | 0.002 | −1.668 | * | ||
Coefficienta
| 0.029 | 0.017 | 1.674 | * | ||
Coefficientb
| −0.143 | 0.009 | −15.742 | *** | ||
Indirect effect | −0.004 | 0.002 | −1.665 | * | −0.004 | |
Direct effect | −0.008 | 0.009 | −0.874 | −0.008 | ||
Total effect | −0.012 | 0.009 | −1.303 | −0.012 | ||
Proportion of total effect mediated | 35.5 % | |||||
Ratio of indirect to direct effect | 0.550 | |||||
Ratio of total to direct effect | 1.550 | |||||
DV: public expentitures; IV: TRP; MV: volumes | ||||||
Sobel | −0.020 | 0.012 | −1.769 | * | ||
Goodman-1 (Aroian) | −0.020 | 0.012 | −1.769 | * | ||
Goodman-2 | −0.020 | 0.012 | −1.769 | * | ||
Coefficienta
| −0.025 | 0.014 | −1.770 | * | ||
Coefficientb
| 0.810 | 0.014 | 56.677 | *** | ||
Indirect effect | −0.020 | 0.012 | −1.769 | * | −0.020 | |
Direct effect | 0.010 | 0.011 | 0.905 | 0.010 | ||
Total effect | −0.010 | 0.016 | −0.643 | −0.010 | ||
Proportion of total effectmediated | 197.9 % | |||||
Ratio of indirect to direct effect | −2.021 | |||||
Ratio of total to direct effect | −1.021 | |||||
DV: public expentitures; IV: TRP (long run); MV: volumes | ||||||
Sobel | −0.022 | 0.007 | −3.241 | *** | ||
Goodman-1 (Aroian) | −0.022 | 0.007 | −3.241 | *** | ||
Goodman-2 | −0.022 | 0.007 | −3.242 | *** | ||
Coefficienta
| −0.027 | 0.008 | −3.246 | *** | ||
Coefficientb
| 0.810 | 0.014 | 56.679 | *** | ||
Indirect effect | −0.022 | 0.007 | −3.241 | *** | −0.022 | |
Direct effect | 0.036 | 0.007 | 5.556 | *** | 0.036 | |
Total effect | 0.014 | 0.009 | 1.534 | 0.014 | ||
Proportion of total effect mediated | −152.2 % | |||||
Ratio of indirect to direct effect | −0.604 | |||||
Ratio of total to direct effect | 0.396 | |||||
DV: public expentitures; IV: TRP; MV: private expenditures | ||||||
Sobel | −0.003 | 0.003 | −0.902 | |||
Goodman-1 (Aroian) | −0.003 | 0.003 | −0.9 | |||
Goodman-2 | −0.003 | 0.003 | −0.904 | |||
Coefficienta
| 0.020 | 0.022 | 0.904 | |||
Coefficientb
| −0.143 | 0.009 | −15.742 | *** | ||
Indirect effect | −0.003 | 0.003 | −0.902 | −0.003 | ||
Direct effect | 0.010 | 0.011 | 0.905 | 0.010 | ||
Total effect | 0.007 | 0.012 | 0.621 | 0.007 | ||
Proportion of total effect mediated | −40.2 % | |||||
Ratio of indirect to direct effect | −0.287 | |||||
Ratio of total to direct effect | 0.713 |