软预算约束外文文献翻译中英文.docx

软预算约束外文文献翻译中英文.docx

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软预算约束外文文献翻译中英文

软预算约束外文翻译中英文2020

英文

Determinantsofsoftbudgetconstraints:

HowpublicdebtaffectshospitalperformanceinAustria

MichaelBerger,MargitReichmann,ThomasCzypionka

Abstract

Softbudgetconstraints（SBCs）underminereformstoincreasehospitalserviceefficiencywhenhospitalmanagementcancountonbeingbailedoutby（subnational）governmentsincaseofdeficits.Usingcostaccountingdataonpubliclyfinanced,non-profithospitalsinAustriafrom2002to2015,weanalysetheassociationbetweenSBCsandhospitalefficiencychangeinasettingwithnegligibleriskofhospitalclosureinatwo-stagestudydesignbasedonbias-correctednon-radialinput-orienteddataenvelopmentanalysisandordinaryleastsquaresregression.WefindthattheEuropeandebtcrisisalteredthepatternofhospitalefficiencydevelopment:

aftertheeconomiccrisis,hospitalsinlow-debtstateshada1.1percentagepointlowerannualefficiencychangecomparedtohospitalsinhigh-debtstates.Nosuchsystematicdifferenceisfoundbeforetheeconomiccrisis.Theresultssuggestthatsuddenexogenousshockstopublicfinancescanincreasethebudgetarypressureonpubliclyfinancedinstitutions,therebycounteractingapre-existingSBC.

Keywords:

Dataenvelopmentanalysis,Softbudgetconstraints,Hospitalefficiency,Bootstrapping,Publicdebt,Hospitalbudgets

1. Introduction

Intheirquesttosafeguardthefinancialsustainabilityofhealth-caresystems,policymakersinseveralcountrieshaveimplementedreformstargetingtheefficiencyofhealth-careserviceprovisioninpublichospitals.Aprimeexampleistheintroductionofpaymentsbasedonprospectivediagnosis-relatedgroups（DRGs）（see Dan（2013）, Kittelsenetal.（2007）,butalso WagstaffandMoreno-Serra（2009） forsurveys）.Yettheeffectivenessofthesereformsisunderminedaslongaspublichospitalscanexpecttobebailedoutintimesoffinancialdistress,typicallybysubnationalgovernments.Indeed,publichospitalsareoftensubjecttoasoftbudgetconstraint（SBC）,i.e.‘an exante behaviouralregularity,whichexertsaninfluenceonthefirm'sdecision’（Kornai,1979, 1986）.Hospitalbailoutsareoftentheonlypoliticallyviableoptionathandwhenpolicymakerswanttoavoidsnubbingtheirconstituency.

Brekkeetal.（2015） and ShenandEggleston（2009） usetheinverseoftheprobabilityofahospitalclosureasameasureofbudgetarysoftness.Inmanycases,however,theprobabilityofhospitalclosureconvergestowardszero,iftheprobabilityofbailoutisvirtually100%inpractice.Alternatively,theproblemcanbeexpressedviathefederalgovernments'commitmentnottobailoutadditionalexpenditureatthelocallevel（see BordignonandTurati（2009））.Thecentralissue,however,remainsunchanged:

Whyshouldhospitalmanagementcareaboutefficiencyandnotsimplyactasabudget-maximizingbureaucrat,asoutlinedinNiskanen'smodelofbureaucracy（Niskanen（1968））?

Mostlikely,therewillbeanimplicitupperlimitonthemaximumdeficitthatistoleratedwithouttheowners/financiersreplacingthemanagement.Hospitalmanagementhencefacesthedilemmaofmaximizinghospitalbudgetandavoidingbeinglaidoff.Usingtheprobabilityofabailoutasameasureofthesoftnessofbudgetaryconstraintsneglectsthisdimension.

Whenhospitalclosuresareunlikely,thereisanadditionalcaveattotheapproachusedby Brekkeetal.（2015） and ShenandEggleston（2009）.Iftheprobabilityofhospitalclosureconvergestowardszeroforallhospitals,thebudgetaryconstraintisequallysoftforallhospitalsandthereshouldbenosystematicdifferencesintheefficiencychangesbetweenhospitalgroups.However,weproposethatsystematicdifferencesinefficiencychangecanindeedbeobservedincountrieswithsubnationalautonomylikeAustria.Whilethelikelihoodofhospitalclosureapproacheszero,thedebtburdenofthestates,whichultimatelyhavetoabsorbanyhospitaldeficitswithinthestate,significantlyinfluencesthedegreeofbudgetarysoftness,leadingtosystematicdifferencesinstate-levelhospitalefficiencychanges.Thefinancialcrisisin2009andthesubsequentEuropeandebtcrisisconstitutedastrongexogenousshocktoAustria'spublicfinances.EUlegislation,adoptedasaconsequenceofthedebtcrisis,furtherexposedso-called‘hiddendebts’inAustria,includingthedebtofpubliclyownedhospitals.Itislikelythatrevealingthe‘hiddendebt’ofpublichospitalsfurtheraggravatedtheproblemofpublicdebt,i.e.thecompliancewiththeMaastrichtcriteria,inthepoliticaldomain.Akeyhypothesisforthepresentanalysisisthatstateswithrelativelyhighpublicdebtwerehithardestbythisdevelopment,whichconsiderablylimitedthefinancialleewayofthesestategovernments.Thefinancialcrisis,therefore,causedariftinthebudgetaryconstraintsofhospitalsinhigh-debtstates,tiltingthedilemmaofhospitalmanagementtowardshigherbudgetarydisciplinebymakingrunningdeficitsintheaftermathofthefinancialcrisismoreproblematic.

TheempiricalevidencefromAustriaisofinterestforthefollowingreasons:

theAustrianDRGsystemdoesnotcovertheentirecostsofpubliclyandprivatelyownednon-profithospitalsprovidingpubliclyfundedacutecare（forsimplicityreferredtoas‘publichospitals’henceforth）.Itonlystipulatesthatatleast51%ofhospitalcostshavetobefinancedoutofmarket-likerevenues（Bundesgesetzblatt,2017b）,therebyimplementingarathersoftbudgetconstraint.The51%-rulewassupposedtoensurethatpublichospitalscouldstillbeassignedtotheprivatesectoraccordingtotheEuropeanSystemofAccounts1995）（ESA）（Bundesgesetzblatt,2005）.Anyextracostmustbebornebyregionalauthorities（stategovernmentsandmunicipalities）andthehospitalowners（Bundesgesetzblatt,2017a）.Inthepast,publiclyownedhospitalsorhospitalcompaniescouldcountontherecoveryofanyextracost,notleastbecauseofthehighpoliticalpressuretoensurepublichospitalcare.Since2010,however,theESAhasdeemedthatanydebtthestateisheldliableformustbeassignedtothepublicsector.Asaconsequence,anydeficitsofpublichospitalscauseanincreaseintheratioofgovernmentdebttogrossdomesticproduct（GDP）andthusendangercompliancewiththeStructuralPact2012（StP2012）（Bundesgesetzblatt,2013）,whichratifiedtheTreatyonStability,CoordinationandGovernanceintheEconomicandMonetaryUnion（2012）.Federal,stateandlocalgovernmentsagreedtosustainablycomplywithasystemofmultiplefiscalrulesintroducedin2017toincreasebudgetarydiscipline.Non-compliancetriggersfinancialsanctionmechanisms,representingamajorinnovationcomparedtotheMaastrichtcriteria.

Thepurposeofthispaperisthreefold:

firstly,weinvestigatewhetherdifferentdegreesofSBCcanariseevenwhenhospitalclosureisnotapoliticallyviableoption.Asthisisascenariothatmayoccurquitefrequentlyforpublichospitals,weadapttheapproachformodellingSBCusedin Brekkeetal.（2015） and ShenandEggleston（2009） tobetteraccountforsuchsituationsbyusingpublicdebtasanindicatorofbudgetarysoftness.Secondly,weusethefinancialcrisisin2009andtheensuingEuropeandebtcrisisasanexogenousshocktothestates’financialsituationsinourstudyframework,whichaffectshospitalefficiencychangesviatheSBC,eventhoughtheprobabilityofhospitalclosureremainsnegligible.Duetosomemethodicalchallengesrelatedtothedatainthisstudy,ourstudydesigndoesnotallowacausalinterpretationoftheresults.Ourresultsshould,therefore,beconsideredasexplorativeratherthanasdefinitiveempiricalevidence.Theliteraturefurthersuggeststhatthereisalsoanassociationbetweenhospitalownershipandefficiency（see,e.g. Chenetal.（2019） forashortoverviewoftherelevantliterature）orownershipandbudgetconstraints（see,e.g. Eggleston（2008））.Againstthisbackground,wethirdlyassesswhetherprivateownersresponddifferentlytochangesinthebudgetaryconstraintscomparedtopublicowners.Toserveourpurposesweuseatwo-stagestudydesigncombiningdataenvelopmentanalysis（DEA）withsubsequentregressionanalysis.

2. Literaturereview

ResearchintotheSBCstartedwithtwoseminalpapersby Kornai（1979, 1986）,whointerpretedanSBCasafiscalresponseofthegovernmenttoavoidunemploymentandsecurepublicservicesintimesofrecession. Kornai,Maskin,andRoland（2003）broadenedtherangeofSBCinstruments,includingtaxconcessionstofostercertainproducers,andadministrativerestrictionsandimporttariffstohampercompetitors.TheoreticalmodelsthatattempttopredicttheoccurrenceofanSBCarereviewedby Maskin（1996） whoconcludesthatthecentralizationofcreditallocationandproductionaswellaspublicownershipofcapitalpromoteSBC.

Morerecentcontributionsrecognizethatabudgetconstraintmaybenotonlysoftenedbutalsotightened. BerteroandRondi（2000） showthatpublicenterprisesrespondpositivelyintermsofproductivitytoashiftfromsofttohardbudgetconstraintswhile BesfamilleandLockwood（2008） predictthatinafederalcountry,hardbudgetconstraintsmaycauseregionalgovernmentstounderprovidepublicgoodsintheirattempttomaintainbudgetbalance.

Recently,severalstudieshavelinkedSBCtheoryspecificallytothebehaviourandperformanceofhospitals. Brekkeetal.（2015） notethatanSBCnotonlycoversadeficitbutmayalsoentailconfiscationofprofit.Theypredictanegativeassociationbetweentheprobabilitiesofbailoutandprofitconfiscationontheonehandandcost-containmenteffortsontheother.Asregardscostefficiency, Wright（2016）,consideringtheresponsesofbothpublichosp