TRFS: desenvolvimento de um protótipo para simulação microscópica de tráfego

Dissertação para obtenção do grau de Mestre em Engenharia Civil na Área de Especialização de Vias de Comunicação e Transportes

Economic analysis in health care regulation : three essays

ABSTRACT - It is the purpose of the present thesis to emphasize, through a series of examples, the need and value of appropriate pre-analysis of the impact of health care regulation. Specifically, the thesis presents three papers on the theme of regulation in different aspects of health care provision and financing. The first two consist of economic analyses of the impact of health care regulation and the third comprises the creation of an instrument for supporting economic analysis of health care regulation, namely in the field of evaluation of health care programs. The first paper develops a model of health plan competition and pricing in order to understand the dynamics of health plan entry and exit in the presence of switching costs and alternative health premium payment systems. We build an explicit model of death spirals, in which profitmaximizing competing health plans find it optimal to adopt a pattern of increasing relative prices culminating in health plan exit. We find the steady-state numerical solution for the price sequence and the plan’s optimal length of life through simulation and do some comparative statics. This allows us to show that using risk adjusted premiums and imposing price floors are effective at reducing death spirals and switching costs, while having employees pay a fixed share of the premium enhances death spirals and increases switching costs. Price regulation of pharmaceuticals is one of the cost control measures adopted by the Portuguese government, as in many European countries. When such regulation decreases the products’ real price over time, it may create an incentive for product turnover. Using panel data for the period of 1997 through 2003 on drug packages sold in Portuguese pharmacies, the second paper addresses the question of whether price control policies create an incentive for product withdrawal. Our work builds the product survival literature by accounting for unobservable product characteristics and heterogeneity among consumers when constructing quality, price control and competition indexes. These indexes are then used as covariates in a Cox proportional hazard model. We find that, indeed, price control measures increase the probability of exit, and that such effect is not verified in OTC market where no such price regulation measures exist. We also find quality to have a significant positive impact on product survival. In the third paper, we develop a microsimulation discrete events model (MSDEM) for costeffectiveness analysis of Human Immunodeficiency Virus treatment, simulating individual paths from antiretroviral therapy (ART) initiation to death. Four driving forces determine the course of events: CD4+ cell count, viral load resistance and adherence. A novel feature of the model with respect to the previous MSDEMs is that distributions of time to event depend on individuals’ characteristics and past history. Time to event was modeled using parametric survival analysis. Events modeled include: viral suppression, regimen switch due virological failure, regimen switch due to other reasons, resistance development, hospitalization, AIDS events, and death. Disease progression is structured according to therapy lines and the model is parameterized with cohort Portuguese observational data. An application of the model is presented comparing the cost-effectiveness ART initiation with two nucleoside analogue reverse transcriptase inhibitors (NRTI) plus one non-nucleoside reverse transcriptase inhibitor(NNRTI) to two NRTI plus boosted protease inhibitor (PI/r) in HIV- 1 infected individuals. We find 2NRTI+NNRTI to be a dominant strategy. Results predicted by the model reproduce those of the data used for parameterization and are in line with those published in the literature.

A theoretical and practical study on linear reforms of dual taxes

We extend the linear reforms introduced by Pf¨ahler (1984) to the case of dual taxes. We study the relative effect that linear dual tax cuts have on the inequality of income distribution -a symmetrical study can be made for dual linear tax hikes-. We also introduce measures of the degree of progressivity for dual taxes and show that they can be connected to the Lorenz dominance criterion. Additionally, we study the tax liability elasticity of each of the reforms proposed. Finally, by means of a microsimulation model and a considerably large data set of taxpayers drawn from 2004 Spanish Income Tax Return population, 1) we compare different yield-equivalent tax cuts applied to the Spanish dual income tax and 2) we investigate how much income redistribution the dual tax reform (Act ‘35/2006’) introduced with respect to the previous tax.

La imposición de los carburantes de automoción en España: algunas observaciones teóricas y empíricas

This article deals with the taxation of private car fuels in Spain,analyzing its theoretical foundations and carrying out a comparativestudy of tax design and tax levels. Moreover, we estimate a demandsystem of car fuels with data from Encuesta Continua de PresupuestosFamiliares, which allows for microsimulation of various tax reforms. Inparticular, we evaluate and assess the effects of the new Spanish taxon car fuel sales and of the application in Spain of the EU directiveon harmonization of energy taxes.

A theoretical and practical study on linear reforms of dual taxes

[cat] En aquest treball extenem les reformes lineals introduïdes per Pfähler (1984) al cas d’impostos duals. Estudiem l’efecte relatiu que els retalls lineals duals d’un impost dual tenen sobre la distribució de la desigualtat -es pot fer un estudi simètric per al cas d’augments d’impostos-. Tambe introduïm mesures del grau de progressivitat d’impostos duals i mostrem que estan connectades amb el criteri de dominació de Lorenz. Addicionalment, estudiem l’elasticitat de la càrrega fiscal de cadascuna de les reformes proposades. Finalment, gràcies a un model de microsimulació i una gran base de dades que conté informació sobre l’IRPF espanyol de l’any 2004, 1) comparem l’efecte que diferents reformes tindrien sobre l’impost dual espanyol i 2) estudiem quina redistribució de la riquesa va suposar la reforma dual de l’IRPF (Llei ’35/2006’) respecte l’anterior impost.

A theoretical and practical study on linear reforms of dual taxes

[cat] En aquest treball extenem les reformes lineals introduïdes per Pfähler (1984) al cas d’impostos duals. Estudiem l’efecte relatiu que els retalls lineals duals d’un impost dual tenen sobre la distribució de la desigualtat -es pot fer un estudi simètric per al cas d’augments d’impostos-. Tambe introduïm mesures del grau de progressivitat d’impostos duals i mostrem que estan connectades amb el criteri de dominació de Lorenz. Addicionalment, estudiem l’elasticitat de la càrrega fiscal de cadascuna de les reformes proposades. Finalment, gràcies a un model de microsimulació i una gran base de dades que conté informació sobre l’IRPF espanyol de l’any 2004, 1) comparem l’efecte que diferents reformes tindrien sobre l’impost dual espanyol i 2) estudiem quina redistribució de la riquesa va suposar la reforma dual de l’IRPF (Llei ’35/2006’) respecte l’anterior impost.

Modelling the consequences of a reduction in alcohol consumption among patients with alcohol dependence based on real-life observational data.

BACKGROUND: Most available pharmacotherapies for alcohol-dependent patients target abstinence; however, reduced alcohol consumption may be a more realistic goal. Using randomized clinical trial (RCT) data, a previous microsimulation model evaluated the clinical relevance of reduced consumption in terms of avoided alcohol-attributable events. Using real-life observational data, the current analysis aimed to adapt the model and confirm previous findings about the clinical relevance of reduced alcohol consumption. METHODS: Based on the prospective observational CONTROL study, evaluating daily alcohol consumption among alcohol-dependent patients, the model predicted the probability of drinking any alcohol during a given day. Predicted daily alcohol consumption was simulated in a hypothetical sample of 200,000 patients observed over a year. Individual total alcohol consumption (TAC) and number of heavy drinking days (HDD) were derived. Using published risk equations, probabilities of alcohol-attributable adverse health events (e.g., hospitalizations or death) corresponding to simulated consumptions were computed, and aggregated for categories of patients defined by HDDs and TAC (expressed per 100,000 patient-years). Sensitivity analyses tested model robustness. RESULTS: Shifting from >220 HDDs per year to 120-140 HDDs and shifting from 36,000-39,000 g TAC per year (120-130 g/day) to 15,000-18,000 g TAC per year (50-60 g/day) impacted substantially on the incidence of events (14,588 and 6148 events avoided per 100,000 patient-years, respectively). Results were robust to sensitivity analyses. CONCLUSIONS: This study corroborates the previous microsimulation modeling approach and, using real-life data, confirms RCT-based findings that reduced alcohol consumption is a relevant objective for consideration in alcohol dependence management to improve public health.

Development of a population-based cost-effectiveness model of chronic graft versus host disease in Spain

Chronic graft-versus-host disease (cGvHD) is the leading cause of late nonrelapse mortality (transplant-related mortality) after hematopoietic stem cell transplant. Given that there are a wide range of treatment options for cGvHD, assessment of the associated costs and efficacy can help clinicians and health care providers allocate health care resources more efficiently. OBJECTIVE: The purpose of this study was to assess the cost-effectiveness of extracorporeal photopheresis (ECP) compared with rituximab (Rmb) and with imatinib (Imt) in patients with cGvHD at 5 years from the perspective of the Spanish National Health System. METHODS: The model assessed the incremental cost-effectiveness/utility ratio of ECP versus Rmb or Imt for 1000 hypothetical patients by using microsimulation cost-effectiveness techniques. Model probabilities were obtained from the literature. Treatment pathways and adverse events were evaluated taking clinical opinion and published reports into consideration. Local data on costs (2010 Euros) and health care resources utilization were validated by the clinical authors. Probabilistic sensitivity analyses were used to assess the robustness of the model. RESULTS: The greater efficacy of ECP resulted in a gain of 0.011 to 0.024 quality-adjusted life-year in the first year and 0.062 to 0.094 at year 5 compared with Rmb or Imt. The results showed that the higher acquisition cost of ECP versus Imt was compensated for at 9 months by greater efficacy; this higher cost was partially compensated for ( 517) by year 5 versus Rmb. After 9 months, ECP was dominant (cheaper and more effective) compared with Imt. The incremental cost-effectiveness ratio of ECP versus Rmb was 29,646 per life-year gained and 24,442 per quality-adjusted life-year gained at year 2.5. Probabilistic sensitivity analysis confirmed the results. The main study limitation was that to assess relative treatment effects, only small studies were available for indirect comparison. CONCLUSION: ECP as a third-line therapy for cGvHD is a more cost-effective strategy than Rmb or Imt.

Comparaisons de projections des niveaux d'incapacité de la population canadienne de 65 ans et plus en 2031

Le vieillissement de la population canadienne prévisible dans les prochaines années entrainera d’importants changements au point de vue social. L’un d’eux est l’augmentation fulgurante du nombre d’aînés en état d’incapacité. Utilisant le modèle de microsimulation LifePaths, cette recherche compare deux projections, ayant des méthodologies différentes, du nombre d’individus en incapacité de 65 ans et plus vivant en ménage privé en 2031. La première méthode utilise le module d’incapacité de LifePaths pour générer les individus en incapacité tandis que la seconde méthode utilise plutôt une régression logistique ordonnée pour les obtenir. Les projections du nombre d’individus en état d’incapacité des deux méthodes nous permettent une comparaison entre ces résultats. Suite à l’élaboration de tableaux et de graphiques permettant de tracer un portait de la situation, cette recherche essaie de démystifier les sources possibles à l’origine de ces différences. Les résultats montrent d’importantes différences entre les projections, spécifiquement pour les individus en état d’incapacité sévère. De plus, lorsqu’on s’intéresse aux variables d’intérêts, on remarque que les différences de projections d’effectifs sont importantes chez les hommes et les gens mariés. Par contre, lorsque les proportions sont analysées, c’est plutôt le groupe d’âges 80 ans et plus ainsi que les projections pour la province du Québec qui créent problème. Ces différences sont attribuables aux caractéristiques d’un modèle de microsimulation, aux populations de départ ainsi qu’aux paramètres définis. Les résultats démontrés dans cette recherche mettent en garde sur les travaux étudiant le nombre d’individus en incapacité dans le futur. Nos deux méthodes ayant des résultats différents, nous ne pouvons pas conclure avec certitude quelle sera la situation dans le futur.

Poverty impacts of agricultural policy adjustments in an opening economy: the case of Colombia

We aim to contribute to the assessment of poverty impacts on the rural sector arising from agricultural policy adjustments in Colombia. For this we use an agriculture specialized static CGE model, jointly (sequentially) with a microsimulation model that allows for effective job relocation. Results indicate that the sectoral impact of the program implemented tends to be small and has considerable variability across crops. They also show that the highest impacts come from the irrigation and land improvements component of the program. Lastly, although it reduces poverty, poverty impacts are small and tend to concentrate in rural households toward the middle of the income distribution ladder.

Seguros de desempleo: revisión de literatura y propuesta para Colombia

En este artículo se estudia la posibilidad de introducir seguros de desempleo en Colombia. En una primera parte, se propone una revisión de literatura de los seguros de desempleo en la cual se exponen las ventajas generadas por una cobertura contra este riesgo, así como sus inconvenientes. En una segunda parte, se estudian varios escenarios para introducir seguros de desempleo en Colombia. Después de haber presentado el contexto del mercado laboral y de las normas que lo vigilan, se proponen varios diseños que abordan la gestión y la administración del riesgo de desempleo en Colombia. Igualmente se presentan algunas consideraciones teóricas para la valoración del costo del aseguramiento, las cuales incorporan los efectos del riesgo moral sobre la duración y la incidencia del desempleo.

Análisis de supervivencia en pacientes con prótesis valvular biológica, Fundación Cardioinfantil-Instituto de Cardiología, Colombia, 2005-2013

Introducción: A partir de la década de los cincuenta el manejo de la enfermedad valvular presenta cambios significativos cuando se incorporan los reemplazos valvulares tanto mecánicos como biológicos dentro de las opciones de tratamiento quirúrgico (1). Las válvulas biológicas se desarrollaron como una alternativa que buscaba evitar los problemas relacionados con la anticoagulación y con la idea de utilizar un tejido que se comportara hemodinámicamente como el nativo. Este estudio está enfocado en establecer la sobrevida global y la libertad de reoperación de la válvula de los pacientes sometidos a reemplazo valvular aórtico y mitral biológicos en la Fundación Cardioinfantil - IC a 1, 3, 5 y 10 años. Materiales y métodos: Estudio de cohorte retrospectiva de supervivencia de pacientes sometidos a reemplazo valvular aórtico y/o mitral biológico intervenidos en la Fundación Cardioinfantil entre 2005 y 2013. Resultados: Se obtuvieron 919 pacientes incluidos en el análisis general y 876 (95,3%) pacientes con seguimiento efectivo para el análisis de sobrevida. La edad promedio fue 64años. La sobrevida a 1, 3, 5 y 10 años fue 95%,90%,85% y 69% respectivamente. El seguimiento efectivo para el desenlace reoperación fue del 55% y se encontró una libertad de reoperación del 99%, 96%, 93% y 81% a los 1, 3, 5 y 10 años. No hubo diferencias significativas entre la localización de la válvula ni en el tipo de válvula aortica empleada. Conclusiones: La sobrevida de los pacientes que son llevados a reemplazo valvular biológico en este estudio es comparable a grandes cohortes internacionales. La sobrevida de los pacientes llevados a reemplazo valvular con prótesis biológicas en posición mitral y aortica fue similar a 1, 3, 5 y 10 años.

Proposta e avaliação de uma política pública contra a desigualdade econômica no Brasil: a sociedade de participantes

Este trabalho propõe e avalia ex-ante uma política pública, denominada Sociedade de Participantes, para reduzir a desigualdade econômica no Brasil. Para tanto, inicialmente se discute os efeitos da desigualdade no tecido social e no desenvolvimento econômico de um país. Em seguida, apresenta os conceitos básicos de justiça distributiva, contrapondo os ideais da direita liberal e os da esquerda distributiva, e sustentando que a política proposta equilibra os desejos destas duas correntes. O passo seguinte é a quantificação do fenômeno econômico em pauta, a desigualdade, sendo então apresentada uma metodologia inédita no Brasil, que permite analisar a contribuição para a desigualdade de cada setor econômico e unidade geográfica da federação. Também são expostas medidas éticas de desigualdade, até agora não discutidas em nossa literatura, que possibilitam avaliar o bem-estar de uma população. A proposta é então discutida detalhadamente, sendo analisadas as políticas semelhantes que estão sendo implantadas em outros países, levantando-se os prós e contras em relação à política de renda mínima garantida e dialogando-se com as críticas contra a política proposta existentes na literatura. Para a avaliação ex-ante da Sociedade de Participantes é necessário um ferramental específico, que inclui conceitos de microssimulação e demografia, discutidos na etapa seguinte. Para sua implementação discute-se também uma mudança no sistema tributário nacional, fortemente embasado em tributos indiretos com características regressivas, e a adoção de um imposto sobre riquezas, que é quantificado no estudo. Finalmente, são apresentados os resultados, simulados entre 2008 e 2080, da avaliação ex-ante da Sociedade de Participantes, na qual se conclui que ela é altamente efetiva para combater a desigualdade e a pobreza endêmica no Brasil.

The distribution of average and marginal effective tax rates in European Union member states

Macro-based summary indicators of effective tax burdens do not capture differences in effective tax rates facing different sub-groups of the population. They also cannot provide information on the level or distribution of the marginal effective tax rates thought to influence household behaviour. I use EUROMOD, an EU-wide tax-benefit microsimulation model, to compute distributions of average and marginal effective tax rates across the household population in fourteen European Union Member States. Using different definitions of ‘net taxes’, the tax base and the unit of analysis I present a range of measures showing the contribution of the tax-benefit system to household incomes, the average effective tax rates applicable to income from labour and marginal effective tax rates faced by working men and women. In a second step, effective tax rates are broken down to separately show the influence of each type of tax-benefit instrument. The results show that measures of effective tax rates vary considerably depending on incomes, labour market situations and family circumstances. Using single averages or macro-based indicators will therefore provide an inappropriate picture of tax burdens faced by large parts of the population.

Income distribution in Argentina, 1974-2000

Includes bibliography