Health services research – Gianluca Fiorentini

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Health services research – Gianluca Fiorentini

 Office hours
– E-mail gianluca.fiorentini@unibo.it for
an appointment
– Meetings will be arranged on TEAMS
– In person: Wednesday 8.00-10.00,
Department of Economics, 3rd floor,
piazza Scaravilli 1
– Changes in the Office hours are posted on
the personal homepage
– For further information, send an e-mail
Health services research – Gianluca Fiorentini
 The course «philosophy» and the nature
of the health systems
- Sustainability (cost containment) is regarded by
several scholars as the main challenge for the
health systems in the next decades
- For public health systems this implies also a
challenge to guarantee universal coverage and
equitable access to services
- There are no dominant strategies, and one needs
to understand the nature and complexity of the
«problems» – taking a systemic and
multidisciplinary approach - before analysing the
details of specific «solutions»
Health services research – Gianluca Fiorentini
 A systemic and multidisciplinary approach
- The choice of the institutional setting to finance
healthcare (single-payer, insurance market,
mixed settings) has deep implications for the
organization of service provision at all levels
- The choice of an efficient model for the supply of
hospital services depends on the organization of
the primary care services
- Decisions are taken by professionals (and
patients) that are not perfect agents of the
payers/providers (e.g. lack of compliance,
defensive medicine, supply induced demand)
Health services research – Gianluca Fiorentini
The role of interest groups in framing the issues
- There are permanent conflicts between different
interest groups (payers, providers of goods and
services, physicians, patients) calling for
regulation using different institutional tools,
organizational models, payment mechanisms and
incentives
- Economic interests play a relevant role in how
«problems» are framed and in the choice of the
«solutions» on which to focus the analysis
- One must be aware of the political consequences
of focussing only on few ready-made solutions
Health services research – Gianluca Fiorentini
 How to reason on problems and solutions

Asch et al. New England Journal of Medicine

(2014)

Health services research – Gianluca Fiorentini

 Ash - In-sourcing healthcare innovations
How innovations (policies) should be thought
of, and tried, in healthcare organisations
It provides useful suggestions for consultants
on how to think of problems and solutions
- 1 Contextual inquiry
- 2 Problem definition: re-framing
- 3 Deliberate divergence
- 4 Rapid validation

Health services research – Gianluca Fiorentini

 Ash - Insourcing healthcare innovations

1 Framing – Contextual inquiry

- How the issue is framed (media,
institutional reports, focus groups,
questionnaires)?
- What is your experience of the issue and
that of the colleagues? (identities, analogies,
differences)
- What is the relevant scientific literature?
(not only health economics or management,
not only the last 5 years, need for an
Health services research – Gianluca Fiorentini
 Insourcing healthcare innovations
2 Problem definition - Re-Framing
What are the real issues at stake? Are you
tackling a problem or a (ready-made)
solution?
- Supplementary insurance for ageing; the
point is proximity to death and
inappropriate use of new technology?
- Organizational solutions in primary care
(medical homes, community hospitals);
the point is to how to coordinate different
professions?
Health services research – Gianluca Fiorentini
 Insourcing healthcare innovations
- Risk stratification as a tool for pro-active
primary care (DCG-PCG): the point is to find
somebody (GPs?) able to bear the risks
- Closure of small hospitals/units (volume-
quality) in favour of large specialised centres
(focused factories): the point is how to elicit
cooperation in hub&spoke networks
- Waiting times for diagnostic tests….
Link solutions to specific interest groups
Health services research – Gianluca Fiorentini
 Insourcing healthcare innovations
3 Deliberate divergence
- Find alternative “solutions” (if any) for the
real problems at stake (see list above)
- Evaluate all the relevant aspects of the new
“solutions”: assumptions, allocative
implications, distributive consequences
- Compare the new “solutions” with the
dominant ones (are there countries, regions,
organizations where the solutions do work?)

Health services research – Gianluca Fiorentini

 Insourcing healthcare innovations

4 Rapid validation - Pre-testing

- Build up a (simple) model of solution
and try mental experiments to verify how
it may work in face of foreseeable
obstacles
- Try to single out the fundamental
parameters of your own model
- Conduct some sensitivity analysis

Health services research – Gianluca Fiorentini

 Outline of the course
1. Ageing and sustainability
2. Population health management
3. Accountable care organizations
4. Chronic care and multimorbidities
5. Clinical pathways
6. Research value and waste
7. Research funding and outcomes
8. Information disclosure on outcomes

Health services research – Gianluca Fiorentini

 Outline of the course

1 Ageing and sustainability of the health

systems
1) Demographic challenges and the
«instrumental» use of forecasting techniques
2) Implications for public finance equilibria and
limitations of different policy solutions
3) The contribution of health economists to a new
conceptual frame for the sustainability problem
4) New appraisal of the policy problem and the
search for new solutions
5) The current political debate
Health services research – Gianluca Fiorentini
 Outline of the course
2 Population health management
1) Why are ageing and «population health
management» so closely related?
2) Conflicting definitions of population health
management
3) Population health management and the «triple
aim» movement in the US
4) How to avoid the «triple fail» situations
5) Implementation problems of the «triple aim» in
the US
Health services research – Gianluca Fiorentini
 Outline of the course
3 Accountable care organizations

1) Population health and accountable care

organizations in the US/UK
2) Population health and accountable care
organizations elsewhere
3) People centered health care and integrated
care: the WHO perspective

Health services research – Gianluca Fiorentini

 Outline of the course
4 Chronic care and multimorbidities
1) Definition of comorbidity and multiple
morbidities
2) The impact of multiple morbidities on mortality,
quality of life, use of the health services
3) Multimorbidities and fragmentation of supply
4) Implications for research, guidelines, primary
care, medical homes, chronic care models
5) Epidemiology of multimorbidities: ageing and
socio-economic status
6) Effectiveness of integrated care models with
moltimorbidities
Health services research – Gianluca Fiorentini
 Outline of the course
5 Clinical pathways
1) Clinical pathways as complex interventions to
implement patient-centered models, to elicit
interdisciplinary cooperation and to foster
integration between levels of care
2) Different operational models of CPWs (Chain,
hub and web)
3) The quest for patients’ involvement
4) Existing evidence on the effectiveness of
CPWs and of integrated care models

Health services research – Gianluca Fiorentini

 Outline of the course
6 Research value and waste
- Different types of scientific research
- How to set the «right» research priorities
(clinicians, patients, payers)
- Lack of use of previous literature
- The replicability problem
- The publication bias against negative results
- Lack of interdisciplinary research
- Funding and the careers of researchers (bias)
- Mapping the research portfolio

Health services research – Gianluca Fiorentini

 Outline of the course
7 Research funding and outcomes
Funding
- Health research funding: a comparative analysis
- Research performance in terms of health gains
- The main grant-makers and their priorities
Outcomes
- Bibliometric indicators and patents
- Capital value of biomedical corporations
- Normative proposals to foster research
- The social role of biomedical research
Health services research – Gianluca Fiorentini
 Outline of the course

8 Information disclosure on outcomes

Problems with outcome ratings
- Clinical and crowd-sourced nursing homes
ratings
- Possibility to game on ratings
- Clinical and crowd-sourced hospital ratings
Health and economic consequences of ratings
- Ratings and their effects on demand
- Ratings and their effects on future quality

Health services research – Gianluca Fiorentini

 Slides and References
- Slides are available on the Insegnamenti On
Line (IOL) platform
- References are provided in each set of slides and
on the IOL platform
- Downloads from any Unibo connection (or at
home with a proxy) to all:
– scientific papers
– institutional reports
- Unibo provides free access to scientific journals
and several books/handbooks (e.g. OUP)
Health services research – Gianluca Fiorentini
 Oral/Written Exams
- Especially for those unable to attend
classes, there will be a oral/written exam
with 2/3 questions
- Students have to answer to (write a short
essay for) each of the 2/3 questions
- There will be a list of sample questions to
help prepare for the oral/written exam
- Time for the written exam: 1,5 hours
- In case of written exam, there will be no
oral examination
Health services research – Gianluca Fiorentini
 Presentations
- Students can choose to give a presentation
(typically in the week after the end of the
course, but this year in the first week of June)
- The presentation is on a topic covered during
the course and agreed beforehand
- Each presentation is expected to last about 10-
15 minutes, and is followed by a short
discussion
- Students are expected to participate in the
discussion of the presentations

Health services research – Gianluca Fiorentini

 Purpose of the presentations

To strengthen the students’ ability to frame a

problem which is relevant and to defend a thesis
through:
- a critical selection of the relevant literature
(explaining the mapping and the selection of
the relevant sources);
- the drafting of a short report drawing critically
on some of the literature’s results, adding
personal ideas and suggestions;
- a defence in front of peers/colleagues.

Health services research – Gianluca Fiorentini

 How to frame the presentation
Suppose the CEO of the organization you are
working for (as employee or as consultant) asked
you to analyse a problem;
The CEO does not ask you to find a unique
solution, but to reach a better understanding of
the problem’s main features and of its relevance
for the organisation;
The CEO is interested in knowing whether other
organisations have already faced the problem and
made strategic choices.
Health services research – Gianluca Fiorentini
 Structure of the presentation
1. Clear identification of the problem;
2. What is the strategy for the selection of the
relevant literature;
3. Analysis of the literature taking into account its
methodological limitations;
4. Discussion of the main results of the literature
and of its utility for the problem at stake;
5. Implications for the organizations and
suggestions to the CEO;
6. References.

Health services research – Gianluca Fiorentini

 The discussion/evaluation of the presentation
Presentations are followed by a 5 min. discussion
focussed on whether the speaker:
1. clearly explained what was the problem;
2. motivated her selection of the sources;
3. critically analysed the limitations of the
literature;
4. clearly explained the results of the literature
and the possibility to make use of them in the
current context;
5. was able to provide some helpful suggestions
Health services research – Gianluca Fiorentini