Due to the European Cross-Border Directive, the provision of quality healthcare in EU implies for patients the possibility to decide to receive medical treatments in their residential country or to move to non-residential ones. Such option is likely to disclose both positive effects and unintended consequences. This chapter investigates healthcare mobility issues by adopting a dynamic performance management view (i.e., combining building blocks of performance management and system dynamics). The outcome of the research is a causal model tailored to the Italian case and depicting key actors, processes, and relationships within a comprehensive feedback structure. The chapter frames the phenomenon of patients' mobility into the public management theory, describes the modelling steps, and proposes quantitative simulations of alternative policies. Such approach can prospectively support policymakers' decisions, contributing to the debate on how to deliver sustainable care at a state level and hypothesizing scenarios following a sustained application of the new EU regulations.
TopIntroduction
One of the key priorities of the European Union is to favor an achievable and effective patients’ mobility (Forchielli & Fusco, 2008), to be intended as a manifestation of the free movement of people, goods and services, physiological constituents of the EU. Cross-border healthcare improves the patients’ choice and can balance health care accessibility, quality, financial sustainability and equity (Wismar et al., 2011).
The scale of cross-border healthcare is still relatively modest, accounting just for the 1% of the total EU healthcare expenditure (Van Ginneken & Busse 2011), but the attention to the phenomenon is growing, due to the relatively recent adoption of the European directive on the “Application of patients’ rights in cross-border healthcare” (2011/24/EU). Indeed, patients’ mobility could compensate temporary disequilibria between supply and demand, and stimulate healthcare enhancements in both sending and receiving countries, for example by creating pressure to reduce waiting times and revealing weaknesses in administrative processes, such as patient registrations and data flows (Rosenmoller et al., 2006, p. 184).
On the other side, the directive opens up to relevant issues, in particular for the coverage of the difference between home and destination countries’ medical tariffs, inducing patients to make healthcare choices according to pure economic convenience rather than quality (Simonetti et al., 2014, p. 641). For this reason, a delicate balance needs to be found by enforcing local healthcare systems without deterring the mobility option.
The importance to target local health care is inner to the cross-border directive, which fosters coordination between Member States from a broader health system perspective (Clemens et al., 2014) and can provide an opportunity for Member States to reform long-standing health issues.
Given the above challenges, innovative managerial tools are required for steering European health care. The Italian healthcare system, public-funded and regionalized, is not new to the phenomenon of healthcare mobility, since it witnesses every year conspicuous patients’ flows from certain regions to others. These movements converge into the notion of in-border mobility, or inter-regional mobility. According to the Italian regulation, the regional healthcare departments are responsible for health: on the one hand, they have to ensure the provision of essential level of health care; on the other side, they cannot deny to patients the chance to access other regional medical care. Then the residential regions will financially compensate the destination regions for the health care to non-residents. Since there are constant patients’ outflows always generated by the same under-developed regions, such figures can represent indicators of low quality of the local healthcare offers.
The present chapter has three scopes:
- 1)
To support policy makers in strategic decisions.
- 2)
To contribute to the debate about how to provide sustainable care at a country level.
- 3)
To favor learning processes by hypothesizing potential scenarios following a sustained application of the new EU regulations.
In order to pursue the above aims, the chapter combines performance management and system dynamics simulation modelling. Such framework can represent for key stakeholders a valuable mean to raise awareness about the feedback structure responsible for the Italian inter-regional mobility flows. Indeed, the Italian mobility, in the author’s view, has relevant similarities with the cross-border dynamics, which will be better explained later on in the text.
The chapter will follow this path: after this introductive paragraph about the topic and the aims of the study, there will be a description of the European and Italian legislations and a literature review about the main factors affecting the healthcare mobility. Then the patients’ flows will receive a further analysis by framing them into the public management theories. Starting from that, the progressive introduction of the system dynamics combined with performance management items, will preannounce the proposal of a dynamic performance management framework. Finally, the discussion of the theoretical and managerial implications of the study will take place, as well as a call for future researches.