Publications

This paper examines the unintended strategic effects of non-linear incentives in public policies. A system of health care subsidies structured into discrete intervals may lead to strategic behaviour. We provide new evidence on this issue, focusing on a case where strategic actions are taken by healthcare providers (HCPs). We show that HCPs adjust the score of claimants in long-term care needs assessments, allowing claimants to access higher levels of care benefits. This adjustment does not bring any pecuniary gain for HCPs. In a quasi-natural experimental setting –the implementation of Spanish long-term care (LTC)– we show that the distribution of the claimants' needs includes kinks around the thresholds set for the LTC system. These kinks reveal that healthcare providers adopt prosocial behaviour, helping claimants jump to a higher level of benefits without discriminating by health status, residence, or gender. By developing a new non-parametric estimator, we prove that these adjustments increase the public LTC spending, which is equivalent to moving thresholds to the left. The additional cost per adjusted claimant per annum is approximately 1000 euro on average. Finally, we also explore empirically whether the number of thresholds could affect such behaviour, by exploiting a reform that eliminated some thresholds. We find that the lower number of thresholds is associated with an increase of adjustment around the thresholds that remain.

(Previously circulated as Against the Discontinuity Trap: the Case of Long-Term Care in Spain)

This paper estimates effects of long-term care (LTC) benefits on utilization of primary and secondary healthcare in Catalonia (Spain). Identification comes from plausibly exogenous variation in the leniency of LTC needs assessment. We estimate that receiving LTC benefits worth 365 euros per month, on average, reduces the probability of avoidable hospital admissions by 66%, and has no significant effect on planned hospitalisations nor on hospitalisation for any reason. Receiving LTC benefits is estimated to reduce unscheduled primary care visits by 44% and has no significant effect on scheduled visits. These findings have important policy implications suggesting that allocating resources to LTC may not only increase the welfare of LTC beneficiaries but also reduce avoidable and unscheduled utilisation of healthcare.

We study the socioeconomic horizontal inequity in the allocation of publicly subsidised long-term care (LTC) in Spain, using administrative data from the universe of applicants in Catalonia. We find that, after controlling for needs, cash subsidies for informal care are disproportionately concentrated among wealthier individuals, while the use of formal care services (home care and nursing homes) is concentrated among the less well-off. This suggests that cash benefits may inadvertently facilitate access to wealthier individuals’ private care. We also find inequity in the form of provision, with in-kind services being more prevalent among the worse-off while wealthier beneficiaries are more likely to receive vouchers. While this duality in provision does not lead to significant differences in overall time to access LTC, we find that lower-income individuals wait longer for telecare, and wealthier individuals opting for in-kind nursing home care wait longer, suggesting potential differences in preferences or constraints. We find no evidence of socioeconomic inequity in the time spent navigating the administrative application process. Our findings highlight the need for policymakers to consider the potential unintended consequences of cash benefits and different forms of provision to ensure equitable access to LTC services.

Background: Physical activity is associated with mental health benefits. This systematic literature review summarises extant evidence regarding this association, and explores differences observed between populations over sixty-five years and those younger than sixty-five. Methods: We reviewed articles and grey literature reporting at least one measure of physical activity and at least one mental disorder, in people of all ages. Results: From the 2263 abstracts screened, we extracted twenty-seven articles and synthesized the evidence regarding the association between physical (in)activity and one or more mental health outcome measures. We confirmed that physical activity is beneficial for mental health. However, the evidence was mostly based on self-reported physical activity and mental health measures. Only one study compared younger and elder populations, finding that increasing the level of physical activity improved mental health for middle aged and elder women (no association was observed for younger women). Studies including only the elderly found a restricted mental health improvement due to physical activity. Conclusions: We found inverse associations between levels of physical activity and mental health problems. However, more evidence regarding the effect of ageing when measuring associations between physical activity and mental health is needed. By doing so, prescription of physical activity could be more accurately targeted.

While the benefits of physical activity on health are well documented, in high-income countries 1 in 3 adults do not reach the recommended levels. Thus, policy makers have developed interventions to promote physical activity. The aim of this research is to evaluate the effectiveness of physical activity prescription on mental health outcomes, by studying an intervention that prescribes physical activity at the primary care level in Catalonia (PAFES). This intervention specifically targets the adult population with high cardiovascular risk. We use data from the Health Survey of Catalonia (2011-2016) and exploit the variation in the number of trained General Practitioners that prescribe physical activity. Our results show that physical activity prescription reduces the probability of suffering from poor mental health. This effect is mainly driven by females within the targeted population. We also explore the main effect (or the output) of the intervention. While PAFES increases the probability of patients undertaking high-level physical activity, it does not affect rates of sedentarism or minutes walked per day. Results are consistent when using alternative mental health outcome measures, including self-reported depression and anxiety. We conclude that the prescription of physical activity not only contributes to the improvement of physical health but is also a useful tool to help preserve mental wellbeing.