EuHEA Seminar Series 2023/2024

The EuHEA seminar series brings together health economists all across its member associations, and beyond, to discuss cutting-edge research

Welcome

The EuHEA Seminar Series has been established as a key activity of EuHEA to foster exchange between health economists across countries and institutions and present cutting-edge research in all areas of health economics. A Scientific Committee chaired by Céu Mateus and Bruce Hollingsworth (Lancaster University), Pedro Pita Barros (Universidade Nova de Lisboa), and Karine Lamiraud (ESSEC Paris) will coordinate the series in the academic year 2023/2024. Seminars are held online and will take place on Tuesdays, 1:30-2:30pm (CET). For details on the program, see below.

The series in fall 2023 will run from October 3 until December 19.

The series in Spring 2024 will run from March 12 until June 25.

Sessions can be accessed by clicking here.

 

Program Spring 2024

12 March 2024, 1:30-2:30pm (CET)

Multimarket competition and pharmaceutical firms’ exit decision

   

Speaker: Carolina Santos, Nova School of Business and Economics
Discussant: Georges Siotis
Chair: tbd

19 March 2024, 1:30-2:30pm (CET)

Building Health across Generations: Unraveling the Impact of Early Childcare on Maternal Health

   

Speaker: Laia Bosque-Mercader
Discussant: tbd
Chair: tbd

23 April 2024, 1:30-2:30pm (CET)

Examining pay gaps in the female-dominated (long-term) care sector: Evidence from Portugal

   

Speaker: Viktoria Szenkurök
Discussant: tbd
Chair: tbd

30 April 2024, 1:30-2:30pm (CET)

Managerial Practices and Altruism in Health Care Delivery

   

Speaker: David Contreras Loya
Discussant: tbd
Chair: tbd

7 May 2024, 1:30-2:30pm (CET)

Behavioural Responses to Disability Insurance Generosity: Evidence from administrative records on CVD shocks

   

Speaker: Irene Simonetti
Discussant: tbd
Chair: tbd

14 May 2024, 1:30-2:30pm (CET)

Physician gender and patient health care

   

Speaker: Katrin Zocher
Discussant: tbd
Chair: tbd

21 May 2024, 1:30-2:30pm (CET)

The Effect of Centralised Procurement on Pharmaceutical Marketing and Innovation: Evidence from China

  

Speaker: Chuanzi Yue
Discussant: tbd
Chair: tbd

28 May 2024, 1:30-2:30pm (CET)

Taboo trade-off aversion in choice behaviours: a discrete choice model and application to health-related decisions

  

Speaker: Nicholas Smeele
Discussant: tbd
Chair: tbd

4 June 2024, 1:30-2:30pm (CET)

Opioid Epidemic: The Role of Friends

   

Speaker: Effrosyni Adamopoulou
Discussant: tbd
Chair: tbd

11 June 2024, 1:30-2:30pm (CET)

The gendered impact of COVID-19 on health behaviours and mental health: Evidence from the UK

   

Speaker: Karen Arulsamy
Discussant: tbd
Chair: tbd

18 June 2024, 1:30-2:30pm (CET)

Drug tenancy thresholds, consumption and newborn's health

  

Speaker: Grace Armijos Bravo
Discussant: tbd
Chair: tbd

25 June 2024, 1:30-2:30pm (CET)

Depends on whom you ask: discrepancies in reporting spousal care between women and men across European welfare states

   

Speaker: Ricardo Rodrigues
Discussant: tbd
Chair: tbd

 

Program Fall 2023

3 October 2023, 1:30-2:30pm (CET)

Triage at Shift Changes and Distortions in the Perception and Treatment of Emergency Patients

In this study, we employ more than one million Emergency Department (ED) records and combine machine learning and regression discontinuity techniques to quantify previously undocumented distortions in triage nurses’ assessment of patients’ conditions and to investigate the short- and medium-run consequences for patients. We show that triage nurses tend to assign lower priority at the beginning of their shifts, and then become progressively more lenient. As a consequence, identical patients arriving at the ED just after a shift change are assigned a substantially lower priority than patients arriving just before. We employ this setting in a regression discontinuity design to show that identical patients assigned lower priority (because of this distortion) are then treated as if they were in less severe conditions and are more likely to be discharged without further care and are more likely to demand further emergency care over the following months. We interpret this as evidence that distortions in nurses’ initial assessment of patients’ urgency bias physicians’ perceptions of the conditions of the patients with long-run implications for their health and for the healthcare service.

Speaker: Simone Ferro, Università degli Studi di Milano Statale
Discussant: Igor Francetic, University of Manchester
Chair: Pedro Pita Barros, Nova School of Business of Economics

10 October 2023, 1:30-2:30pm (CET)

Violence against women: The witness dilemma

In Spain, the reform of the Violence Against Women (VAW) law (Royal Decree-Law 9/2018) made it possible to report gender violence without going to the police or court. The advantage of this kind of “soft reporting” is that victims or witnesses can report to social services and thereby gain access to legal, economic and psychological support without having to identify or denounce the aggressor. It is expected that the availability of soft reporting will help to reduce costs and overcome barriers to reporting. The goal of this paper is to evaluate the impact of soft reporting on witness involvement (the decision to report). We also analyze witness preferences and the sensitivity of potential witnesses to different costs associated with soft and hard reporting. This aspect of witness reporting has not been evaluated in Spain, and it has potentially wide relevance for other countries in Europe who are interested in adopting similar kinds of legislation. To perform this evaluation, we follow an experimental approach, embedded in an official survey conducted by the Institute of Statistics of the Government of Navarra (Spain). We find that potential witnesses are more willing to intervene when soft reporting is available. In addition, we find that the individual propensity to intervene and help the victim decreases when costs increase. We identify the switching point at which individual propensity to intervene starts to decrease, and find that it is the same for both soft and hard reporting scenarios. Finally, we find that altruistic individuals and those who belong to feminist associations are more inclined to intervene. We discuss the implications of these findings for policy makers.

Speaker: Ariadna Garcia Prado, Universidad Pública de Navarra
Discussant: Judit Vall Castelo, UB School of Economics
Chair: Céu Mateus, Lancaster University

17 October 2023, 1:30-2:30pm (CET)

Into the Far West? Investigating Health Policy-Makers' Willingness to Adopt Decrementally Cost-Effective Innovations Using a DCE Approach

Objectives
In a context of increasingly limited resources, a number of strategies, such as the adoption of decrementally cost-effective interventions (d-CEIs), which are both less clinically effective and less costly, could offer potential levers at enhancing both efficiency and equity in healthcare systems. These interventions are located in the South-West quadrant of the cost-effectiveness plane, and have yet received little attention as they are often perceived as per se “unethical” or “unacceptable”, hence the reference sometimes made to the S-W quadrant as the 'Far West'.

The purpose of our paper is to understand preferences and determinants to d-CEIs' adoption by health policy-makers. To the best of our knowledge, no previous study has inquired into health policy-makers' preferences regarding d-CEIs. Our study therefore fills a significant gap in the literature by studying health policy-makers' preferences regarding d-CEIs in a number of countries in Europe in order to identify the conditions that would allow their consideration as comparators in HTAs and their possible adoption in replacement to usual care.

Method:

We use a two-stage pairwise discrete choice experiment (DCE) survey to elicit (i) preferences for d-CEIs' attributes in forced choices and (ii) adoption preferences, i.e. the determinants of d-CEIs' adoption (unforced choices). We investigate the effect (and trade-offs) between three attributes: health loss (very small to significant), reversibility defined as the possibility to switch back to usual care (from possible to hardly possible) and cost-savings (from 5% to 15% of a fixed budget). Such trade-offs are contextualized by using two sensitivity attributes: disease severity (low and moderate) and savings uncertainty (low and high). Our final sample consists of 180 respondents with 46.7% originating from France and the remaining respondents from other EU countries.

Results:

All attributes’ levels have a significant effect in the two decision stages. The ”health loss” attribute dominates in the first stage followed by ”reversibility”: we calculate that decision-makers would require 28.3% increase of budget savings to be indifferent between a scenario of small
versus significant health losses and 14.5% to be indifferent between a scenario of possible and hardly possible reversibility. In contrast, the ”reversibility” attribute dominates in the second stage suggesting that anticipated regret may play a role in adoption decisions.

A stratified analysis of the compensation requirements according to participants’ responses of the follow-up
questions in the second stage (i.e., ”would you be ready to substitute usual care by the option you selected ” and ”would you be ready to substitute usual care by the option selected if disease severity of the patient -before treatment- changes to
moderate”), reveals the existence of preference heterogeneity across participants.

Speaker: Iván Tzintzun Valladolid, Paris School of Economics
Discussant: Petra Baji, University of Bristol
Chair: Bruce Hollingsworth, Lancaster University

24 October 2022, 1:30-2:30pm (CET)

A Healthy Start for Healthy Start Vouchers?

This paper examines the impact of a recent increase in the value of healthy start vouchers (HSV) on the purchase of healthy items, using a large and representative sample of 13 million shopping basket transactions from a major UK food retailer. We use a difference-in-differences (DiD) approach to show that a £1.15 increase in voucher values increased spending on fruits and vegetables (F&V) for single voucher users by 32p and for two voucher users by 77p. For all eligible items, the increase in the value of the vouchers increased spending by 31p for single voucher users and by 89p for two voucher users. Our analysis of the marginal propensity to consume (MPC) indicates that consumers treat vouchers similarly to cash transfers of the same value. We also find that the effects of the HSV program are greater in more deprived areas and areas with lower pre-change expenditure on eligible items, indicating potential benefits for reducing health inequalities. Our results have implications for the effectiveness of targeted benefit programs, such as the UK HSV program, in promoting healthy food choices.

Speaker: Hamideh Mohtashami Borzadaran, University of Birmingham
Discussant: Mario Martinez, Imperial College London
Chair: Pedro Pita Barros, Nova School of Business and Economics

31 October 2023, 1:30-2:30pm (CET)

Impact of Forced Sterilization on Female Labor Market Outcomes: Evidence from India

Objective: I investigate the impact of the 1975-76 forced sterilization campaign carried out by the Indira Gandhi government in India on women’s long-run labor market outcomes.

Methods: I exploit heterogeneity in the implementation of coercive sterilization at the district level using difference-in-differences (DiD) and run additional robustness and heterogeneity checks.

Results: Using large data samples from India and accounting for endogeneity concerns, I find that exposure to the forced sterilization campaign at the district level reduces long-term labor market participation by 4.5% and 1.5% in agricultural and sales occupations and increases unemployment by 4.7% and I elucidate mechanisms.

Discussion: The proposed mechanism of this is the disutility derived from having a working wife. This result is contrary to existing literature that indicates that women’s
access to contraception increases their labor market participation. My results suggest that giving women access to contraception is insufficient to improve their market outcomes.

Speaker: Niranjana Prasad, Université Catholique de Louvain
Discussant: Saurabh Singhal, Lancaster University
Chair: Bruce Hollingsworth, Lancaster University

7 November 2022, 1:30-2:30pm (CET)

Multimarket competition and pharmaceutical firms’ exit decision

Objectives: Multimarket contacts (MMC), which correspond to firms’ overlap across markets, may facilitate tacit collusion and thus reduce the intensity of competition. While there is extensive evidence that MMC decrease within-market competition, this study aims to evaluate whether multimarket contacts also influence market participation decisions, in the Portuguese off-patent drug market.

Methods: Resorting to a simple theoretical model of multimarket competition, it is shown that the potential of MMC to enhance collusion may depend on the ability of these contacts to restore an overall symmetry between companies which may fail to be observed in individual markets. As existing empirical MMCmeasures fail to account for this, this paper puts forward a theory-founded measure which weights contacts between companies by their importance in smoothing market share asymmetries. Based on the proposed theory-founded MMC measure, the paper tests whether pharmaceutical firms with greater MMC have greater survival chances in individual markets. The monthly dataset, ranging from January 2018 until December 2021, comprised on average 199 companies and 260 markets.

Results: Based on linear probability models with fixed effects and conditional logit models, it is shown that when the unit of analysis is the firm-in-market (i.e., a firm in a given market) higher MMC with competitors do not influence pharmaceutical firms’ survival chances in individual markets. Nonetheless, when the unit of analysis is a market, higher average MMC between companies active in a market are associated with a lower probability of observing firms’ exit from that market. Indeed, if MMC in a given market increase by one unit, then the probability of observing at least one firm exit the market over the course of one year decreases by 1.14 percentage points. These distinct results suggest that the degree of mutual forbearance is essentially a feature of the individual market under consideration, and not a characteristic of inter-firm rivalry independent of the level of competition faced by other competitors in the market.

Conclusions: While cost savings in the retail prescription drug market crucially depend on competition from generic drug producers, the results from this study suggest that these savings may be lower than expected due to the mutual forbearance incentive that MMC create. The finding that greater multimarket connections between companies soften competition and, consequently, decrease firms’ exit rates gives strength to the argument that drug prices (even off-patent drug prices) need to be regulated through price caps. Indeed, direct price regulation counters the incentive that multimarket competitors have to attenuate competition.

Speaker: Carolina Santos, Nova School of Business and Economics
Discussant: George Siotis, Universidad Carlos III de Madrid
Chair: Céu Mateus, Lancaster University

14 November 2023, 1:30-2:30pm (CET)

The Electoral Returns to Investing in Healthcare

In this paper, we examine whether voters respond to investments in healthcare and access to health services. We focus on the city of Rio de Janeiro, the Brazilian capital with the highest growth in primary healthcare coverage between 2009 and 2012. The newly elected government in 2008 rapidly expanded the Family Health Program (FHP) in the city, a community healthcare program introduced in Brazil at the municipal level and which is currently the largest in the world. We assess whether the FHP expansion affected the mayor's vote share in 2012 by exploiting extremely fine-grained geocoded variation in access to healthcare and in voting across time and space within the city. The identifying variation comes from changes in the share of voters at the polling booth level residing and enrolled in a FHP catchment area, within polling places fixed effects, triggered by idiosyncratic expansion of catchment areas over the 2008-2012 period. We find that FHP coverage is positively associated with the mayor's vote share. Yet, the magnitude of the FHP effect is higher for the last year of government and increases with the proximity between FHP facilities and individuals' home addresses. Our results also suggest that this impact is accompanied by relatively larger increases in vote share when the services are provided in new health facilities compared to the existing units. The evidence suggests that closer contact with services and the visible side of the service provision may be greatly rewarded by voters. Overall, this paper contributes to a better understanding of voter responsiveness of healthcare policies and its mechanisms.

Speaker: Marcela dos Santos, University of Pittsburgh
Discussant: Mariana Lopes da Fonseca, University of St. Gallen
Chair: Pedro Pita Barros, NOVA School of Business and Economics

21 November 2023, 1:30-2:30pm (CET)

Are the grandparents alright? The health consequences of grandparental childcare provision

This paper examines the causal effect of childcare provision on grandparents’ health in the US. We propose the sex ratio among older adults’ children as a novel instrument for grandparental childcare provision. Our instrument is rooted in the demographic literature on grandparenthood and exploits that parents of daughters transition to grandparenthood earlier and invest more in their grandchildren than parents of sons. We estimate 2SLS regressions using data from the Health and Retirement Study. The results suggest that childcare provision is not beneficial for grandparents’ health and may even be detrimental for physical functioning and subjective health.

Speaker: Emma Zai, Max Planck Institute for Demographic Research
Discussant: Judith Bom, Erasmus School of Health Policy and Management
Chair: Bruce Hollingsworth, Lancaster University

28 November 2023, 1:30-2:30pm (CET)

A Systematic Review of Equity Issues Experienced by Older Adults with Rare Diseases

Objectives:
To summarize the different forms of equity issues that rare disease populations face in comparison to the general population. We are also particularly interested in examining the specific equity issues that older subpopulation of the general rare disease population faces in comparison to the general rare disease population.

Methods:
We conducted a systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and apply a search strategy to MEDLINE via PubMed the Cochrane Library, and Embase based on search terms related to equity and rare diseases. We also considered gray literature of regulatory bodies, patient organizations, industry, and others.

Results:
We retrieved and extracted evidence from in 63 publications from which two evidence clusters and five evidence subclusters emerged, thus constituting our evidence framework. Evidence cluster 1 contained evidence retrieved from publications discussing ethical concepts (subcluster 1: n = 12) and societal preferences (subcluster 2: n= 10). Evidence cluster 2 covered regulations (subcluster 3: n= 33), access to care (subcluster 4: n=3) and health outcomes (subcluster 5: n=5).

Discussion:
Evidence that compared the older rare disease population to the general rare disease population indicated that older adults, as a subgroup of the general rare disease population could potentially encounter more equity issues. This is not surprising because it relates to a general moral and ethical debate on how specific subgroups of patients ought to be treated in societies – i.e., whether resources should be allocated to maximize the welfare of society as a whole; utilitarian , or whether everyone has an equal right to health regardless of health system efficiency; egalitarian
Reetrieved evidence shows that each society is located somewhere along the egalitarian utilitarian continuum and there is hardly any consensus in OECD countries regarding the optimal balance between the two ends of this spectrum.

However, retrieved evidence is insuffcient to enable us to conclude that older rare disease patients face more equity issues in comparison to the general rare disease population. This said, we inductively develop an evidence framework that is reflective of modern health systems and that may help identify specific research gaps. In the long run, this should lead to better understanding of the root causes of inequities, and result in improved access to care and better health outcomes for older adults with rare diseases as well as for other subgroups of the general rare disease population.

Speaker: Jean Pierre Uwitonze, University of Bern
Discussant: Joachim Marti, University of Lausanne
Chair: Céu Mateus, Lancaster University

5 December 2023, 1:30-2:30pm (CET)

Provider and patient delay: Income, utilisation, and multimorbidity predict health care accessibility in Austria, the UK and the USA during the COVID-19 pandemic

Objectives
Access to health care is known to be significantly influenced by the so-called ‘social gradient in health’. This gradient skews access to health care to disfavour socially and economically disadvantaged and deprived groups of the population. In line with this many scholars have highlighted that the COVID-19 pandemic disproportionally affects marginalised and vulnerable groups when it comes to health care. In this article socio-economic-determinants of health are analysed in their implications on health care access and health (in)equity.

Methods
This article uses different survey datasets from Austria, the USA, and the UK to illuminate the interacting effects of health, particularly of multimorbidities, and income on access to health care amidst the COVID-19 pandemic. Employed are various linear and non-linear statistical regression models to investigate the relationships between the variables, including controls, health-related behaviours and robustness checks.

Results
The main findings corroborate the expected health-income gradient effects on health care access with regards to hospitals, general practitioners, specialists, and home care. Unmet needs that are distributed asymmetrically across populations are identified in all three countries despite their different health system designs.

Discussion
Income matters because it not only mitigates having a medical condition but improves health care accessibility for (relatively) healthy persons too. Medical conditions and multimorbidity result in more barriers to health care access as well. In interaction income and health significantly reinforce inequitable access to different providers of health care. These findings have different implications for health policy.

Speaker: Thomas Resch, Medical University of Vienna
Discussant: Carolina Santos, Nova School of Business and Economics
Chair: Bruce Hollingsworth, Lancaster University

12 December 2023, 1:30-2:30pm (CET)

Can interventions help reduce diabetes incidence? Evidence from NHS DPP participation

Diabetes, a serious chronic condition, is a public health concern alongside leading to substantial economic losses. However, type 2 diabetes, is preventable through health and lifestyle changes. We study the effectiveness of behaviour change interventions on health outcomes while considering the case for the Diabetes Prevention Programme implemented in England. Using referral data from at risk (pre-diabetic) population in England, we examine factors that influence participation and whether greater programme attendance can prevent or delay type 2 diabetes diagnosis. We find that participation appears to come from less deprived communities and older age group cohorts. Our results also suggest that provider led delays can plausibly be related with an individual’s lack of incentive to participate in the programme. Since participation is non-random, we uncover causal effects using instrumental variables. We identify the effect of an individual’s level of attendance through programme design components that provide exogenous variation to individual’s participation decision. Our causal estimates indicate that attending an additional session of the programme leads to an average of 2-3% reduction in the likelihood of developing T2D, and this appears to increase with higher levels of attendance. These results appear to indicate some benefit of engaging with the programme and perhaps it may be important to consider improvements in programme design elements that can boost participation.

Speaker: Vasudha Wattal, Manchester University
Discussant: Rita Faria, University of York
Chair: Pedro Pita Barros, NOVA School of Business and Economics

19 December 2023, 1:30-2:30pm (CET)

The role of physician altruism in the physician-industry relationship: Evidence from combining experimental and observational data

Objectives: Altruism is a key professional norm that underlies the physician's role as a representative agent for patients. However, physician behavior can be influenced when private gains enter the objective function. We study the relationship between altruism and physicians' receipt of financial benefits from pharmaceutical manufacturers, as well as the extent to which altruism mitigates physicians' responsiveness to these industry payments.

Methods: We combine data on altruistic preferences for 280 physicians, identified using a revealed preference economic experiment, with information on their receipt of monetary and in-kind transfers from pharmaceutical firms along with drug prescription claims data. We first develop a stylized model of altruism in brand prescription choices and physicians' decisions to engage with drug firms. We then empirically investigate how physician altruism relates to transfers from the pharmaceutical industry to physicians, and whether altruistic preferences are associated with the relation between industry transfers and drug prescribing.

Results: Our findings reveal that physicians with less altruistic preferences obtain industry transfers that are, on average, 112.55% higher in monetary value compared to physicians with stronger altruistic preferences. This difference in payments amounts to 968.37 USD, indicating clear selection of whom pharmaceutical firms target. Furthermore, we observe that positive correlations between industry transfers and higher overall drug costs or brand prescribing rates are predominantly driven by physicians with less altruistic preferences. Our estimates suggest that, when comparing less altruistic physicians with more altruistic physicians, a 1% increase in payments is associated with an additional average increase of 0.005 percentage points (0.027%) in the share of brand drugs prescribed. We find limited evidence that patient vulnerability moderates industry influences among less altruistic physicians.

Discussion: Our results reveal that altruistic preferences are an essential determinant of the strength of physician-industry ties. We therefore provide first empirical evidence for the role of professional norms in the practice of medicine under potential conflicts of interest.

Speaker: Shan Huang, University of Zurich
Discussant: Odd Rune Straume, University of Minho
Chair: Céu Mateus, Lancaster University

 

Scientific Committee

The EuHEA Seminar Series in the academic year 2022/2023 is coordinated by:

  • Karine Lamiraud, ESSEC Business School (Chair)
  • Rossella Verzulli, University of Bologna (Co-Chair)
  • Francesca Barigozzi, University of Bologna
  • Stefan Boes, University of Lucerne
  • Fabrice Etile, Paris School of Economics
  • Geir Godager, University of Oslo
  • Mathias Kifmann, University of Hamburg
  • Shiko Maruyama, Jinan University
  • Nuria Mas, IESE Business School
  • Helen Mason, Glasgow Caledonian University
  • Paolo Pertile, University of Verona
  • Pedro Pita Barros, Universidade Nova de Lisboa
  • Katrin Zocher, University of Linz