The European Journal of Health Economics

, Volume 14, Issue 1, pp 21–39 | Cite as

Federal state differentials in the efficiency of health production in Germany: an artifact of spatial dependence?

Original Paper

Abstract

Due to regional competition and patient migration, the efficiency of healthcare provision at the regional level is subject to spatial dependence. We address this issue by applying a spatial autoregressive model to longitudinal data from Germany at the district (‘Kreis’) level. The empirical model is specified to explain efficiency scores, which we derive through non-parametric order-m efficiency analysis of regional health production. The focus is on the role of health policy of federal states (‘Bundesländer’) for district efficiency. Regression results reveal significant spatial spillover effects. Notably, accounting for spatial dependence does not decrease but increases the estimated effect of federal states on district efficiency. It appears that genuinely more efficient states are less affected by positive efficiency spillovers, so that taking into account spatial dependence clarifies the importance of health policy at the state level.

Keywords

Health production Order-m efficiency Spatial autoregressive model 

JEL Classification

I12 R10 

References

  1. 1.
    Afonso, A., Aubyn, M.St.: Non-parametric approaches to education and health efficiency in OECD countries. J. Appl. Econ. 8, 227–246 (2005)Google Scholar
  2. 2.
    Anderson, C.A., Busch, G., Webb, J.R.: The efficiency of nursing home chains and the implications of Non-Profit status. J. Real Estate Portfolio Manag. 5, 235–245 (1999)Google Scholar
  3. 3.
    Anselin, L.: Spatial econometrics: methods and models. Kluwer Academic Publishers, Dordrecht (1988)Google Scholar
  4. 4.
    Arraiz, I., Drukker, D.M., Kelejian, H.H., Prucha, I.R.: A spatial Cliff-Ord-type Model with Heteroskedastic Innovations: small and large sample results, CESifo Working Paper # 2485 (2008)Google Scholar
  5. 5.
    Augurzky, B., Felder, S., Tauchmann, H., Werblow, A.: Effizienzreserven im Gesundheits-wesen. RWI: Materialien 49 (2009a)Google Scholar
  6. 6.
    Augurzky, B., Krolop, S., Gülker, R., Schmidt, Ch.M., Schmidt, H., Schmitz, H., Schwierz, CH., Terkatz, S.: Krankenhaus Rating Report 2009: Im Auge des Orkans. RWI: Materialien 53 (2009b)Google Scholar
  7. 7.
    Baltagi, B.H., Moscone, F.: Health care expenditure and income in the OECD reconsidered: evidence from panel data. Econ. Model. 27, 804–811 (2010)CrossRefGoogle Scholar
  8. 8.
    Baltagi, B.H., Egger, P., Pfaffermayr, M.: Estimating regional trade agreement effects on FDI in an interdependent world. J. Econom. 145, 194–208 (2008)CrossRefGoogle Scholar
  9. 9.
    Bhat, V.N.: Institutional arrangements and efficiency of health care delivery systems. Eur. J. Health Econ. 3, 215–222 (2005)CrossRefGoogle Scholar
  10. 10.
    Binder M., Broekel T.: Conversion efficiency as a complementing measure of welfare in capability space. MPRA Paper # 7583. (2008)Google Scholar
  11. 11.
    Björkgren, M.A., Fries, B.E., Hakkinen, U., Brommels, M.: Case-mix adjustment and efficiency measurement. Scand. J. Public Health 32, 464–471 (2004)PubMedCrossRefGoogle Scholar
  12. 12.
    Bonaccorsi, A., Daraio, C., Simar, L.: Advanced indicators of productivity of universities—an application of robust nonparametric methods to Italian data. Scientometrics 66, 389–410 (2005)CrossRefGoogle Scholar
  13. 13.
    Cazals, C., Florens, J.P., Simar, L.: Nonparametric frontier estimation: a robust approach. J. Econom. 106, 1–25 (2002)CrossRefGoogle Scholar
  14. 14.
    Chen, A., Hwang, Y.C., Shao, B.: Measurement and sources of overall and input inefficiencies: evidence and implications in hospital services. Eur. J. Oper. Res. 161, 447–468 (2005)CrossRefGoogle Scholar
  15. 15.
    Cliff, A.D., Ord, J.K.: Spatial autocorrelation. Pion, London (1973)Google Scholar
  16. 16.
    Cohen, J.P., Morrison Paul, C.: Agglomeration and cost economies for Washington state hospital services. Reg. Sci. Urban Econ. 38, 553–564 (2008)CrossRefGoogle Scholar
  17. 17.
    Collier, D.A., Collier, C.E., Kelly, T.M.: Benchmarking physician performance. J. Med. Pract. Manag. Part 1, 185–189 (2006)Google Scholar
  18. 18.
    Costa-Font, J., Moscone, F.: The impact of decentralization and inter-territorial interactions on Spanish health expenditure. Empir. Econ. 34, 167–184 (2008)CrossRefGoogle Scholar
  19. 19.
    Crivelli, L., Filippini, M., Lunati, D.: Regulation, ownership and efficiency in the swiss nursing home industry. Int. J. Health Care Finance Econ. 2, 79–97 (2002)PubMedCrossRefGoogle Scholar
  20. 20.
    Daraio, C., Simar, L.: Advanced robust and nonparametric methods in efficiency analysis–methodology and applications. Springer, New York (2007)Google Scholar
  21. 21.
    Deprins, D., Simar, L., Tulkens, H.: Measuring labor inefficiency in post offices. In: Marchand, M., Pestieau, P., Tulkens, H. (eds.) The performance of public enterprises: concepts and measurements, pp. 243–267. North-Holland, Amsterdam (1984)Google Scholar
  22. 22.
    Egger, P., Pfaffermayr, M., Winner, H.: An unbalanced spatial panel data approach to us state tax competition. Econ. Lett. 88, 329–335 (2005)CrossRefGoogle Scholar
  23. 23.
    Greene, W.H.: Econometric analysis, 4th edn. Prentice Hall, Upper Saddle River (2000)Google Scholar
  24. 24.
    Grosskopf, S., Self, S., Zaim, O.: Estimating the efficiency of the system of healthcare financing in achieving better health. Appl. Econ. 38, 1477–1488 (2006)CrossRefGoogle Scholar
  25. 25.
    Haisken-DeNew, J.P., Schmidt, Ch.M.: Inter-industry and inter-region differentials: mechanics and interpretation. Rev. Econ. Stat. 79, 516–521 (1997)CrossRefGoogle Scholar
  26. 26.
    Hall, R.E., Jones, C.I.: The value of health and the rise in health spending. Q. J. Econ. 122, 39–72 (2007)CrossRefGoogle Scholar
  27. 27.
    Harrison, J.P., Coppola, N.M., Wakefield, M.: Efficiency of federal hospitals in the United States. J. Med. Syst. 28, 411–422 (2004)PubMedCrossRefGoogle Scholar
  28. 28.
    Herr, A.: Cost and technical efficiency of german hospitals: does ownership matter? Health Econ. 17, 1057–1071 (2008)PubMedCrossRefGoogle Scholar
  29. 29.
    Herr, A., Schmitz, H., Augurzky, B.: Profit efficiency and ownership of german hospitals. Health Econ. 20, 660–674 (2011)PubMedCrossRefGoogle Scholar
  30. 30.
    Hollingsworth, B.: The measurement of efficiency and productivity of health care delivery. Health Econ. 17, 1107–1128 (2008)PubMedCrossRefGoogle Scholar
  31. 31.
    Hollingsworth, B.: Non-parametric and parametric applications measuring efficiency in health care. Health Care Manag. Sci. 6, 203–218 (2003)PubMedCrossRefGoogle Scholar
  32. 32.
    Hollingsworth, B., Dawson, P., Maniadakis, N.: Efficiency measurement of health care: a review of nonparametric methods and applications. Health Care Manag. Sci. 2, 161–172 (1999)PubMedCrossRefGoogle Scholar
  33. 33.
    Kapoor, M., Kelejian, H.H., Prucha, I.R.: Panel data models with spatially correlated error components. J. Econ. 140, 97–130 (2006)Google Scholar
  34. 34.
    Kathuria, V., Sankar, D.: Inter-state disparities in health outcomes in rural India: an analysis using a stochastic production frontier approach. Dev. Policy Rev. 23, 145–163 (2005)CrossRefGoogle Scholar
  35. 35.
    Kelejian, H.H., Prucha, I.R.: A generalized spatial two-stage least squares procedure for estimation a spatial autoregressive model with autoregressive disturbances. J. Real Estate Finance Econ. 17, 99–121 (1998)CrossRefGoogle Scholar
  36. 36.
    Kelejian, H.H., Prucha, I.R.: A generalized moments estimator for the autoregressive parameter in a spatial model. Int. Econ. Rev. 40, 509–533 (1999)CrossRefGoogle Scholar
  37. 37.
    Kelejian, H.H., Prucha, I.R.: HAC estimation in a spatial framework. J. Econ. 140, 131–154 (2007)Google Scholar
  38. 38.
    Kelejian, H.H., Prucha, I.R.: Specification and estimation of spatial autoregressive models with autoregressive Heteroskedastic disturbances. CESifo Working Paper # 2448. (2008)Google Scholar
  39. 39.
    Kopetsch, T.: Arztdichte und Inanspruchnahme ärztlicher Leistungen in Deutschland: Eine empirische Untersuchung der These von der angebotsinduzierten Nachfrage nach ambulanten Arztleistungen. Schmollers Jahrbuch 127, 373–405 (2007)Google Scholar
  40. 40.
    LeSage, J., Pace, R.K.: Introduction to spatial econometrics. CRC Press, Boca Raton (2009)CrossRefGoogle Scholar
  41. 41.
    McDonald, J.: Using least squares and tobit in second stage DEA efficiency analyses. Eur. J. Oper. Res. 197, 792–798 (2009)CrossRefGoogle Scholar
  42. 42.
    Mobley, L.R.: Estimating hospital market pricing: an equilibrium approach using spatial econometrics. Regional Science and Urban Economics 33, 489–516 (2003)CrossRefGoogle Scholar
  43. 43.
    Moscone, F., Tosetti, E.: Health expenditure and income in the United States. Health Econ. 19, 1385–1403 (2010)PubMedCrossRefGoogle Scholar
  44. 44.
    Moscone, F., Knapp, M., Tosetti, E.: Mental health expenditure in england: a spatial panel approach. J. Health Econ. 26, 842–864 (2007)PubMedCrossRefGoogle Scholar
  45. 45.
    Moscone, F., Knapp, M.: Exploring the spatial pattern of mental health expenditure. J Ment. Health Policy Econ. 8, 205–217 (2005)PubMedGoogle Scholar
  46. 46.
    Papke, L.E., Wooldirdge, J.M.: Econometric methods for fractional response variables with an Application to 401(k) plan participation rates. J. Appl. Econ. 11, 619–632 (1996)CrossRefGoogle Scholar
  47. 47.
    Pilyavsky, A., Staat, M.: Efficiency and productivity change in Ukrainian health care. J. Prod. Anal. 29, 143–154 (2008)CrossRefGoogle Scholar
  48. 48.
    Puig-Junoy, J., Ortun, V.: Cost efficiency in primary care contracting: a Stochastic Frontier cost function approach. Health Econ. 13, 1149–1165 (2004)PubMedCrossRefGoogle Scholar
  49. 49.
    Scheel, H.: Undesirable outputs in efficiency valuations. Eur. J. Oper. Res. 132, 400–410 (2000)CrossRefGoogle Scholar
  50. 50.
    Schwierz, Ch., Wübker, A.: Determinants of avoidable deaths from Ischaemic Heart Diseases in East and West Germany. J. Public Health 18, 309–317 (2010)CrossRefGoogle Scholar
  51. 51.
    Simar, L., Wilson, P.W.: Estimation and inference in two-stage semi-parametric models of production processes. J. Econom. 136, 31–64 (2007)CrossRefGoogle Scholar
  52. 52.
    Sloan, F.A.: Not-for-profit ownership and hospital behavior. In: Culyer, A.J., Newhouse, J.P. (eds.) Handbook of health economics 1B, pp. 1141–1174. Elsevier, Amsterdam (2000)CrossRefGoogle Scholar
  53. 53.
    Staat, M.: The efficiency of treatment strategies of general practitioners. Eur. J. Health Econ. 4, 232–238 (2003)PubMedCrossRefGoogle Scholar
  54. 54.
    Staat, M.: Efficiency of hospitals in Germany: a DEA-bootstrap approach. Appl. Econ. 38, 2255–2263 (2006)CrossRefGoogle Scholar
  55. 55.
    Street, A.: How much Confidence should we place in efficiency estimates? Health Econ. 12, 895–907 (2003)PubMedCrossRefGoogle Scholar
  56. 56.
    Sundmacher, L., Busse, R.: Health care and avoidable mortality in Germany. Technical University Berlin, Mimeo (2009)Google Scholar
  57. 57.
    Thanassoulis, E., Boussofiane, A., Dyson, R.G.: A comparison of data envelopment analysis and ratio analysis as tools for performance assessment. Omega 24, 229–244 (1996)CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  1. 1.University of Basel and CINCH Centre of Health Economics ResearchBaselSwitzerland
  2. 2.Rheinisch-Westfälisches Institut für Wirtschaftsforschung (RWI) and CINCH Centre of Health Economics ResearchEssenGermany

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