Giuseppe Moscelli

Dr Giuseppe Moscelli


Lecturer in Economics
PhD in Econometrics and Empirical Economics

Biography

My teaching

My publications

Publications

Moscelli G, Siciliani L, Gutacker N, Gravelle H (2016) Location, quality and choice of hospital: Evidence from England 2002?2013, Regional Science and Urban Economics 60 pp. 112-124 Elsevier
We investigate (a) how patient choice of hospital for elective hip replacement is influenced by distance, quality
and waiting times, (b) differences in choices between patients in urban and rural locations, (c) the relationship
between hospitals' elasticities of demand to quality and the number of local rivals, and how these changed
after relaxation of constraints on hospital choice in England in 2006. Using a data set on over 500,000 elective
hip replacement patients over the period 2002 to 2013 we find that patients became more likely to travel to a
provider with higher quality or lower waiting times, the proportion of patients bypassing their nearest provider
increased from 25% to almost 50%, and hospital elasticity of demand with respect to own quality increased.
By 2013 average hospital demand elasticity with respect to readmission rates and waiting times were ?0.2
and ?0.04. Providers facing more rivals had demand that was more elastic with respect to quality and waiting
times. Patients from rural areas have smaller disutility from distance.
Gutacker N, Siciliani L, Moscelli G, Gravelle H (2016) Choice of hospital: Which type of quality matters?, Journal of Health Economics 50 pp. 230-246 Elsevier
The implications of hospital quality competition depend on what type of quality affects choice of hospital.
Previous studies of quality and choice of hospitals have used crude measures of quality such as
mortality and readmission rates rather than measures of the health gain from specific treatments. We
estimate multinomial logit models of hospital choice by patients undergoing hip replacement surgery
in the English NHS to test whether hospital demand responds to quality as measured by detailed patient
reports of health before and after hip replacement. We find that a one standard deviation increase in
average health gain increases demand by up to 10%. The more traditional measures of hospital quality
are less important in determining hospital choice.
Moscelli G, Siciliani L, Gutacker N, Cookson R (2017) Socioeconomic inequality of access to healthcare: Does choice explain the gradient?, Journal of Health Economics 57 pp. 290-314 Elsevier
Equity of access is a key policy objective in publicly-funded healthcare systems. However, observed inequalities of access by socioeconomic status may result from differences in patients? choices. Using data on non-emergency coronary revascularisation procedures in the English National Health Service, we found substantive differences in waiting times within public hospitals between patients with different socioeconomic status: up to 35% difference, or 43 days, between the most and least deprived population quintile groups. Using selection models with differential distances as identification variables, we estimated that only up to 12% of these waiting time inequalities can be attributed to patients? choices of hospital and type of treatment (heart bypass versus stent). Residual inequality, after allowing for choice,was economically significant: patients in the least deprived quintile group benefited from shorter waiting times and the associated health benefits were worth up to £850 per person.
Moscelli G, Siciliani L, Tonei V (2016) Do waiting times affect health outcomes? Evidence from coronary
bypass,
Social Science and Medicine 161 pp. 151-159 Elsevier
Long waiting times for non-emergency services are a feature of several publicly-funded health systems. A
key policy concern is that long waiting times may worsen health outcomes: when patients receive
treatment, their health condition may have deteriorated and health gains reduced. This study investigates
whether patients in need of coronary bypass with longer waiting times are associated with
poorer health outcomes in the English National Health Service over 2000e2010. Exploiting information
from the Hospital Episode Statistics (HES), we measure health outcomes with in-hospital mortality and
28-day emergency readmission following discharge. Our results, obtained combining hospital fixed effects
and instrumental variable methods, find no evidence of waiting times being associated with higher
in-hospital mortality and weak association between waiting times and emergency readmission following
a surgery. The results inform the debate on the relative merits of different types of rationing in healthcare
systems. They are to some extent supportive of waiting times as an acceptable rationing mechanism,
although further research is required to explore whether long waiting times affect other aspects of individuals?
life.
Moscelli Giuseppe, Gravelle Hugh, Siciliani Luigi, Gutacker Nils (2018) The Effect of Hospital Ownership on Quality of Care: Evidence from England, Journal of Economic Behavior & Organization 153 pp. 322-344 Elsevier
We investigate whether quality of care differs between public and private hospitals in England using data on 3.8 million publicly-funded patients receiving 133 planned (non-emergency) treatments in 393 public and 190 private hospital sites. Private hospitals treat patients with fewer comorbidities and past hospitalisations. Controlling for observed patient characteristics and treatment type, private hospitals have fewer emergency readmissions. But patients? choice of hospital may influenced by their unobserved morbidity. After instrumenting the choice of hospital type by the difference in distances from the patient to the nearest public and the nearest private hospital, the effect of private ownership changes sign and is statistically insignificant. Similar results are obtained with coarsened exact matching. We also find no quality differences between hospitals specialising in planned treatments and other hospitals, nor between for-profit and not-for-profit private hospitals. Our results show the importance of controlling for unobserved patient heterogeneity when comparing quality of public and private hospitals.
Moscelli Giuseppe, Gravelle Hugh, Siciliani Luigi, Santos Rita (2018) Heterogeneous effects of patient choice and hospital competition on mortality, Social Science & Medicine 216 pp. 50-58 Elsevier
We examine whether the relaxation of constraints on patient choice of hospital in the English National Health Service in 2006 led to greater changes in mortality for hospitals which faced more rivals before the choice reform. We use patient level data from 2002 to 2010 for three high volume emergency conditions with high mortality risk: acute myocardial infarction (AMI) (288,279 patients), hip fracture (91,005 patients), stroke (214,103 patients). Since mortality risk varies by sub-diagnoses of AMI and stroke we include indicators for sub-diagnoses in the covariates. We also allow for the effect of covariates on mortality to differ before and after the 2006 choice reform. We find that the choice reform reduced mortality risk for hip fracture patients by 0.62% (95% CI: 1.22%, 0.01%), compared with the 2002/3?2010/11 mean of 3.5%, but had statistically insignificant negative effects for AMI and stroke. The reform also had heterogeneous effects across AMI and stroke sub-diagnoses, reducing mortality for 3% of AMI patients and 21% of stroke patients. The reduction in hip fracture mortality was greater for more deprived patients. Policies to increase competition and give patients greater choice are likely to have heterogeneous effects depending on details of patient case mix and market conditions.
Moscelli Giuseppe, Jacobs Rowena, Gutacker Nils, Aragón María José, Chalkley Martin, Mason Anne, Böhnke Jan R (2018) Prospective payment systems and discretionary coding - Evidence from English mental health providers, Health Economics Wiley
Reimbursement of English mental health hospitals is moving away from block contracts and towards activity and outcome?based payments. Under the new model, patients are categorised into 20 groups with similar levels of need, called clusters, to which prices may be assigned prospectively. Clinicians, who make clustering decisions, have substantial discretion and can, in principle, directly influence the level of reimbursement the hospital receives. This may create incentives for upcoding. Clinicians are supported in their allocation decision by a clinical clustering algorithm, the Mental Health Clustering Tool, which provides an external reference against which clustering behaviour can be benchmarked. The aims of this study are to investigate the degree of mismatch between predicted and actual clustering and to test whether there are systematic differences amongst providers in their clustering behaviour. We use administrative data for all mental health patients in England who were clustered for the first time during the financial year 2014/15 and estimate multinomial multilevel models of over, under, or matching clustering. Results suggest that hospitals vary systematically in their probability of mismatch but this variation is not consistently associated with observed hospital characteristics.
Longo Francesco, Siciliani Luigi, Moscelli Giuseppe, Gravelle Hugh Stanley Emrys (2019) Does Hospital Competition Improve Efficiency? The Effect of the Patient Choice Reform in England, Health Economics 28 (5) pp. 618-640 John Wiley & Sons
We use the 2006 relaxation of constraints on patient choice of hospital in the English NHS to
investigate the effect of hospital competition on dimensions of efficiency including indicators of
resource management (admissions per bed, bed occupancy rate, proportion of day cases, cancelled
elective operations, proportion of untouched meals) and costs (cleaning services costs, laundry and
linen costs, reference cost index for overall and elective activity). We employ a quasi difference-indifference
approach and estimate seemingly unrelated regressions and unconditional quantile
regressions with data on hospital trusts from 2002/03 to 2010/11. Our findings suggest that
increased competition had mixed effects on efficiency. An additional equivalent rival increased
admissions per bed and the proportion of day cases by 1.1 and 3.8 percentage points, and reduced
the proportion of untouched meals by 3.5 percentage points, but it also increased the number of
cancelled elective operations by 2.6%. Unconditional quantile regression results indicate that
hospitals with low efficiency, as measured by fewer admissions per bed and a smaller proportion of
day cases, are more responsive to competition.