Discussion Paper
No. 2017-25 | May 10, 2017
Ana Rodríguez-Álvarez and Mayte Rosete-Rivero
Spanish public hospital waiting lists: a theoretical and empirical approach

Abstract

The main objective of this work is to study the effects that supply and demand factors have on waiting lists. With this aim, the authors discuss a model which explains the factors that can affect the production of healthcare, demand for healthcare, and finally, the inequalities between health supply and demand. This analysis proves that, due to imbalances between supply and demand, there is an excess of demand that is equal to the waiting lists. This demand excess is called the waiting list function. Hence, the second part of this paper develops an empirical analysis which estimates the function for the waiting lists of Spanish public hospitals for the period 1996 to 2009. As a result of the estimation, the supply and demand factors influencing waiting lists, as well as their evolution, are determined and studied. An imbalance between supply and demand reduces the supply and increases demand resulting in the amount traded by the market being less than potential demand.

JEL Classification:

H4, I3

Links

Cite As

[Please cite the corresponding journal article] Ana Rodríguez-Álvarez and Mayte Rosete-Rivero (2017). Spanish public hospital waiting lists: a theoretical and empirical approach. Economics Discussion Papers, No 2017-25, Kiel Institute for the World Economy. http://www.economics-ejournal.org/economics/discussionpapers/2017-25


Comments and Questions



Anonymous - Referee report 1
May 24, 2017 - 08:46
The paper studies deeply the waiting lists of the national health system (NHS) for the case of the Spanish public hospitals for the period 1996‐2009. Both, a theoretical and empirical analysis of the Spanish NHS waiting lists are performed. The theoretical analysis allows to identify whether the NHS waiting lists are due to the demand or to the supply. Moreover, the determinants of the waiting lists are able to be analyzed as well. Additionally, a rigorous empirical methodology is used to implement the empirical analysis of the theoretical model developed. Using a panel dataset of the case of Spain, the results suggest that the Spanish NHS waiting lists are explained more for determinants affecting the demand than for those influencing the supply, although the budget seems to be an important supply factor which explains the waiting lists. The main contribution of the paper is that the topic under investigation is addressed not only from a theoretical point of view but from the empirical one as well. Moreover, the importance of the topic addressed is very important for the social welfare and in particular for policymaker. Having said that, I have a few comments that the authors could take into account while revising their manuscript. I discuss them in more detail below. Minor comments: 1. I suggest to the authors to discuss a little more whether in the Spanish NHS there exists important differences in terms of waiting list among regions. This analysis could be interesting since the regions in Spain have transferred the health budget. Thus, it should be thought‐provoking to know whether they manage similarly or not the budget. 2. Page 19 refers to Table 4, but there is a mistake since it has to be Table 2. 3. A little editing of the paper is suggested.

Ana Rodríguez-Álvarez and Mayte Rosete-Rivero - anwers to referee 1
June 18, 2017 - 13:46
We thank the referee for his/her valuable comments. The paper has changed and benefited as a result of these insightful suggestions, for which we are grateful. We have carefully addressed all the requested changes. Below, please find below brief summaries of the key issues raised by the referee: Minor comments:1. I suggest to the authors to discuss a little more whether in the Spanish NHS there exists important differences in terms of waiting list among regions. This analysis could be interesting since the regions in Spain have transferred the health budget. Thus, it should be thought‐provoking to know whether they manage similarly or not the budget. Following your suggestions, we have included a little more discussion about the differences that exist in terms of waiting list among regions in the Introduction Section. In Spain, the different regions have elaborated different regulations and action plans regarding waiting lists. The most noteworthy are the so-called Guarantee Laws or “Leyes de Garantía” (regulations approved by the different autonomous communities which receive the status of laws, decrees, rules etc…), which grant patients the right to sub-contract private healthcare services when waiting lists surpass the maximum waiting times and when the service included falls within a “guaranteed” category. Up until 2003 only 5 of the 17 autonomous communities (Navarre Catalonia, Valencia, Andalusia, and Castille-La Mancha), had established maximum delay times for treatment. In 2003 the Spanish NHS Law of Cohesion and Quality implanted a citizen right to obtain healthcare assistance within a maximum waiting time and established the commitment to set up agreed criteria for all the regions in this context. Nevertheless, the establishment of said criteria has proved very unequal. For example, in line with Cañizares and Santos (2011), the maximum waiting time for guaranteed surgical procedures is 60 days in the Community of Valencia and 180 days in Galicia. With respect to specialist medical consultations, the range of days is 15 in Castille-La Mancha and 60 days in the Balearic Islands. Finally, and in the case of diagnostic procedures maximum waiting time ranges from 7 days for Castile-la Mancha to 45 days for Navarre. Given these discrepancies, in 2011, the Ministry of Health approved a Royal Decree with a view to guaranteeing maximum waiting times “under conditions of effective equality” for certain surgical interventions. 2. Page 19 refers to Table 4, but there is a mistake since it has to be Table 2. Thank you for this. The typo has been corrected. 3. A little editing of the paper is suggested.We have corrected the typos and the English language of the paper. In addition, the paper has been edited again by a company specializing in academic editing and translation.

Esther Lafuente-Robledo - WL/WT on NHS
June 14, 2017 - 13:56
This paper is very well thought out and I find very interesting the simple approach that goes from the elementary theory of microeconomics to the construction of an empirical model that reflects well the reality of waiting lists in the Spanish NHS. The formulation of the functions of supply and demand seems to be correct although perhaps it would be convenient in the conclusions to introduce the idea that the incorporation of techniques of ambulatory major surgery can affect waiting lists. This is due to the possible marginal rate of substitution of traditional surgery versus major ambulatory surgery, especially in recent years. Another fact that seems of importance is to emphasize the cost (in days of transitory incapacity) as a consequence of waiting lists. It is an important economic and social cost, although I am uncertain as to whether it is being measured or not. On the demand side, it would be wise to take into account population; Morbidity and life expectancy. Perhaps discuss the possibility of introducing other variables of chronicity (applying some proxy such as incidence of diabetes or some other recent measure of chronicity that guarantees a degree of correctness in terms of measurement). The analysis used by way of elasticities as well as the conclusion reached that demand is what most impacts them deserves attention because it gives clues as to where to act, knowing that, in any case, it is easier to act on the supply rather than the demand side which has already been given to us.

Ana Rodríguez-Álvarez and Mayte Rosete-Rivero - Answers
June 18, 2017 - 13:48
We thank the referee for his/her valuable comments. The paper has changed and benefited as a result of these insightful suggestions, for which we are grateful. We have carefully addressed all the requested changes. Below, please find below brief summaries of the key issues raised by the referee. The article is very well thought out and I find very interesting the simple approach that goes from the elementary theory of microeconomics to the construction of an empirical model that reflects well the reality of waiting lists in the Spanish NHS. The formulation of the functions of supply and demand seems to be correct although perhaps it would be convenient in the conclusions to introduce the idea that the incorporation of techniques of ambulatory major surgery can affect waiting lists. This is due to the possible marginal rate of substitution of traditional surgery versus major ambulatory surgery, especially in recent years. Another fact that seems of importance is to emphasize the cost (in days of transitory incapacity) as a consequence of waiting lists. It is an important economic and social cost, although I am uncertain as to whether it is being measured or not. We have included the following paragraphs in the Conclusions Section: Nowadays, the incorporation of techniques of ambulatory major surgery can positively affect issues relating to waiting lists. This is due to the possible marginal rate of substitution of traditional surgery versus major ambulatory surgery, particularly applicable in recent years. Waiting lists also imply a cost (in days of transitory incapacity) which constitutes an important economic and social cost On the demand side, it would be wise to take into account population; Morbidity and life expectancy. Perhaps discuss the possibility of introducing other variables of chronicity (applying some proxy such as incidence of diabetes or some other recent measure of chronicity that guarantees a degree of correctness in terms of measurement). The analysis used by way of elasticities as well as the conclusion reached that demand is what most impacts them deserves attention because it gives clues as to where to act, knowing that, in any case, it is easier to act on the supply rather than the demand side which has already been given to us. We have also included a footnote to cover this issue:We have considered the possibility of introducing other variables of chronicity (applying some proxy such as, for example, the incidence of diabetes). However, there is no homogeneous measure on a regional basis for these variables during the period considered.

Anonymous - Referee report 2
June 19, 2017 - 10:27
see attached file
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Ana Rodríguez-Álvarez and Mayte Rosete-Rivero - referee response
July 02, 2017 - 15:27
Please see the attached file
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