O financiamento hospitalar e a definição de preços

RESUMO - Inseridos num contexto onde as unidades prestadoras de cuidados de saúde não possuem autonomia para fixar os seus próprios preços, estuda-se através do presente documento o processo de definição de preços do internamento hospitalar português entre 1993 e 2001, no sentido de aferir o grau de sinalização proporcionado ao mercado, uma vez que, na sua essência, um sistema de preços constitui um sistema de incentivos influenciador de comportamentos produtivos ao nível prestador. Utilizou-se a base de dados nacionais do sistema de classificação de doentes Grupos de Diagnóstico Homogéneos e foi caracterizada a evolução e tendência dos pesos relativos dos produtos do internamento hospitalar português. Foi também avaliada a relação da estrutura de preços com a quantidade produzida, a eficiência técnica e as necessidades em saúde da população portuguesa durante o período considerado. Apesar de existir alguma instabilidade durante o período analisado, o ponto de partida e de chegada não diferiu significativamente. Não foi encontrado nenhum padrão de variação que explicasse a instabilidade encontrada entre os produtos mais complexos, mais produzidos ou os que apresentaram maior/menor variação ao longo da década de 90. A hipótese relativa à correlação entre a evolução de preços e as variáveis quantidade, eficiência e necessidades também foi infirmada. Conclui-se que a utilização do sistema de preços constituiu na sua essência um sistema de incentivos neutro, não foi sinalizador para os prestadores e possuiu uma forte correlação com o nível de reposição de custos históricos dos hospitais portugueses.

Code name

The present case-study concerns about the analysis of the sale of Banif Mais, the sub-holding of Banif Group for specialized credit activity, taking into account the bank’s financial situation in 2014. In 2011, Portugal was submitted to an external finance programme carried out by troika which imposed very restricted measures to the financial sector. Subsequently, Banif was not able to accomplish the required results having to appeal to Government financing, being under a recapitalization plan since 2012.

On project finance and the first road concession in Portugal

In broad sense, Project Financing1 as a mean of financing large scale infrastructural projects worldwide has had a steady growth in popularity for the last 20 years. This growth has been relatively unscathed from most economic cycles. However in the wake of the 2007 systemic Financial Crisis, Project Financing was also in trouble. The liquidity freeze and credit crunch that ensued affected all parties involved. Traditional Lenders, of this type of financial instrument, locked-in long-term contractual obligations, were severely hit with scarcity of funding compounded by rapidly increasing cost of funding. All the while, Banks were “rescued” by the concerted actions of Central Banks and other Multi-Lateral Agencies around the world but at the same time “stressed” by upcoming regulatory effort (Basel Committee). This impact resulted in specific changes to this type of long-term financing. Changes such as Commercial Banks’ increased risk aversion; pricing increase and maturities decrease of credit facilities; enforcement of Market Disruption Event clauses; partial responsibility for project risk by Multilateral Agencies; and adoption of utility-like availability payments in other industrial sectors such as transportation and even social infrastructure. To the extent possible, this report is then divided in three parts. First, it begins with a more instructional part, touching academic literature (theory) and giving the Banks perspective (practice), but mostly as an overview of Project Finance for awareness’ sake. The renowned Harvard Business School professor – Benjamin Esty, states2 that Project Finance is a “relatively unexplored territory for both empirical and theoretical research” which means that academic research efforts are lagging the practice of Project Finance. Second, the report presents a practical case regarding the first Road Concession in Portugal in 1998 ending with the lessons learned 10 years after Financial Close. Lastly, the report concludes with the analysis of the current trends and changes to the industry post Financial Crisis of the late 2000’s. To achieve this I’ll reference relevant papers, books on the subject, online articles and my own experience in the Project Finance Department at a major Portuguese Investment Bank. Regarding the latter, with the signing of a confidentiality agreement, I’m duly omitting sensitive and proprietary bank information.

Crowdfunding

Crowdfunding, as we know it today, is a very recent activity that was born almost accidentally in the end of the 90’s decade. Due to the advent of the internet and the social networks, entrepreneurs are now able to promote their projects to a very large community. Whether it is composed by family, friends, acquaintances or simply people that are interested in the same topic or share the passion, the community is able to fund new ventures by individually investing modest amounts of money. In return, the entrepreneur can offer symbolic rewards, shares or other financial returns. New crowdfunding platforms are born almost every day all over the world, offering a new way of raising capital for their projects or a new way to invest their money in innovative ventures. Although crowdfunding is still finding its place in the financial services, successful cases such as Kickstarter demonstrate the power of the crowd in boosting creativity and productivity, financing thousands of projects by raising millions of dollars from thousands of investors. Due to regulatory restrictions, the most prominent model for now is reward-based crowdfunding, where the investors are prized with symbolic returns or privileged access to the products or services offered by the entrepreneurs. Other models such as peer-to-peer lending are also surging, allowing borrowers access to capital at a lower cost compared to so-called traditional financial institutions, and offering lenders a higher rate of return. But when it comes to offering shares to investors, i.e. using equity-based crowdfunding, entrepreneurs face regulatory obstacles in almost every country, where legislation was passed decades ago with the objective of promoting financially-capable ventures and protecting investors. Access to capital has become more difficult after the global economic recession of 2008, and for most countries it will not get easier in the near future, leaving start-ups and small enterprises with few options to start or expand their operations. In this study we attempt to answer the following research questions: how has equity-based crowdfunding evolved since its creation? Where and how has equity-based crowdfunding been implemented so far? What are the constraints and opportunities for implementing equity-crowdfunding in the world, and more particularly in Portugal? Finally, we will discuss the risks of crowdfunding and reflect on the future of this industry.

Vyndaqel (Tafamidis)

The main objective of this pedagogical case study is to analyse the market entry dynamics of pharmaceutical innovative drugs in Portugal, and the role and impact of the different stakeholders in this process. The case focuses on the market entry of Vyndaqel (Tafamidis) Pfizer’s orphan innovative product to treat TTR-FAP, “paramiloidose”, a highly incapacitating rare disease that has more than 2.000 diagnosed patients in Portugal, one of the highest prevalence worldwide and an incidence of 100 new patients every year. In terms of methodology it were used two main sources of information. Regarding secondary data sources it was made an exhaustive search using the main specialty search engines regarding the Tafamidis case, market access, orphan drugs and market entry context in Portugal and Europe. In terms of primary data it were conducted 7 direct interviews with the main case stakeholders. The pedagogical case study focuses on 5 main questions that provide the base of the discussion for the classes. First it is analysed the rationale behind the introduction of Tafamidis in Portugal, and its relevance for Pfizer, namely due to the previous investment made with the acquisition of FoldRX by $400M, the company that developed the product in the first place. It is also analysed the point of view of the NHS, and the reasoning behind drug reimbursement that considered not only the technical (efficacy and safety) and financial benefits of the drug, but also the social impact, due to the major role played by patient associations’ actions and coverage provided by the media that impacted the reimbursement decision. Finally it is analysed the vertical financing methodology that was selected by the Ministry of Health for drug acquisition by 2 public hospitals, that served as reference centres for the treatment of this disease

Promoting hospital-based smoking cessation services at major Swiss hospitals: a before and after study.

Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them. We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits. At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse. A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient.

Economic grand rounds: financial burden of medical care and risk of forgoing care among Europeans with depressive symptoms

Little is known about the financial burden of individuals with depressive symptoms. This study explored that burden, using data from the Survey of Health, Ageing, and Retirement in Europe. To assess the association between depressive symptoms and the individuals' financial burden for medical care and whether they forwent medical care because of costs, logistic regressions were performed that adjusted for age, gender, marital status, education, and chronic diseases. A total of 16,696 noninstitutionalized individuals aged 50-79 years were included in the study. Individuals with depressive symptoms and those without such symptoms bore a similar financial burden. However, individuals with depressive symptoms were at increased risk of forgoing care because of costs, which may worsen their health and financial situation

Bonds away : baseball mythology and the 2007 home run chase

In 2007, Barry Bonds hit his 75 6th home run, breaking Hank Aaron's all-time record for most home runs in a Major League career. While it would be expected that such an accomplishment would induce unending praise and adulationfor the new record-holder, Bonds did not receive the treatment typically reserved for a beloved baseball hero. The purpose of this thesis is to assess media representations of the 2007 home run chase in order to shed light upon the factors which led to the mixed representations which accompanied BOlTds ' assault on Aaron's record. Drawingfrom Roland Barthes ' concept of myth, this thesis proposes that Bonds was portrayed in predominantly negative ways because he was seen as failing to embody the values of baseball's mythology. Using a qualitative content analysis of three major American newspapers, this thesis examines portrayals of Bonds and how he was shown both to represent and oppose elements from baseball's mythology, such as youth, and a distant, agrarian past. Recognizing the ways in which baseball is associated with American life, the media representations of Bonds are also evaluated to discern whether he was portrayed as personifYing a distinctly American set of values. The results indicate that, in media coverage of the 2007 home run chase, Bonds was depicted as a player of many contradictions. Most commonly, Bonds' athletic ability and career achievements were contrasted with unflattering descriptions of his character, including discussions of his alleged use of performance-enhancing substances. However, some coverage portrayed Bonds as embodying baseball myth. The findings contribute to an appreciation of the importance of historical context in examining media representations. This understanding is enhanced by an analysis of a selection of articles on Mark McGwire 's record-breaking season in 1998, and careful consideration of, and comparison to, the context under which Bonds performed in 2007. Findings are also shown to support the contemporary existence of a strong American baseball mythology. That Bonds is both condemned for failing to uphold the mythology and praised for personifYing it suggests that the values seen as inherent to baseball continue to act as an American cultural benchmark.

Erie & Niagara Railway Collection, 1864-1884

William Alexander Thomson (1816-1878) was a promoter and developer of railway systems in western Ontario. He incorporated the Fort Erie Railroad Company in 1857, purchased the Erie and Ontario Railroad in 1863, and incorporated the Erie and Niagara Extension Railway Company in 1868 (later renamed the Canada Southern Railway). Thomson was also elected to the House of Commons for Welland in 1872, and re-elected in 1874. He was known for his support of public management of the currency and is seen as a pioneer advocate of government monetary policy. He was also an advocate of radical agrarian economic doctrine, believing that Canadian laws favoured mercantile interests over those of the producers of goods, and that this hindered national development.

Bank of Canada Records, 1958-1989

The Bank of Canada first introduced Canada Savings Bonds during the First and Second World Wars. At the time, they were known as War Savings Certificates and Victory Bonds and were used to fund the war effort. In 1946, Canada Savings Bonds were used as part of Canada’s Postwar Financing Program. At that time, the government also introduced the sale of bonds through payroll deduction. Canada Savings Bonds proved to be very popular, providing investors with a convenient, flexible and safe investment. Over time the bonds failed to remain competitive with other low-risk investment options, and the high cost of administering the program called into question its relevance. An independent report commissioned by the government in 2004 recommended that the bonds be phased out, however, the government decided to keep the program and make some revisions. As of 2012, Canada Savings Bonds are available exclusively through the payroll savings program, while Canada Premium Bonds (introduced in 1998) are available through financial institutions, dealers and by phone.

Equitable and Inclusive Education for All? Public Funding for Denominational Schools in Ontario

Roman Catholic separate schools’ denominational right to receive public funding is a contentious issue in Ontario’s educational system. Ontario’s publicly funded denominational schools historically served a purpose at Confederation; however, in light of Ontario’s evolving demographics, publicly funding denominational schools today may no longer serve the needs of Ontario. The research problem in this study is expressed through growing problems reconciling Roman Catholic schools with diversity and current public views. Additionally, recent tensions, public views, and political consensus suggest it is time to revisit the existing policy. In order to understand both the history of denominational schools and the present context, this study conducted II policy analyses as its research design by completing 2 policy cycles. The first policy cycle determined that based upon Upper and Lower Canada’s pre-Confederation diversity, extending public funding to denominational schools at Confederation was an effective way of protecting minority rights; however, the analysis in the second policy cycle; which examined how equitable and inclusive denominational schools are today, concluded that the denominational school system no longer serves the diversity and equity needs of contemporary Ontario. Building on these findings, this study then explored two viable alternative educational arrangements for Ontario’s future educational system: publicly funding all faith-based schools, or publicly financing a one-school-system. To address the diversity issue in Ontario, transitioning toward publicly funding a one-school-system is found to be the most viable option.

Non-Commitment and Savings in Dynamic Risk-Sharing Contracts

We characterize the solution to a model of consumption smoothing using financing under non-commitment and savings. We show that, under certain conditions, these two different instruments complement each other perfectly. If the rate of time preference is equal to the interest rate on savings, perfect smoothing can be achieved in finite time. We also show that, when random revenues are generated by periodic investments in capital through a concave production function, the level of smoothing achieved through financial contracts can influence the productive investment efficiency. As long as financial contracts cannot achieve perfect smoothing, productive investment will be used as a complementary smoothing device.

Environmental Risks : Should Banks Be Liable?

This paper studies the impact of banks' liability for environmental damages caused by their borrowers. Laws or court decisions that declare banks liable for environmental damages have two objectives : (1) finding someone to pay for the damages and (2) exerting a pressure on a firm's stakeholders to incite them to invest in environmental risk prevention. We study the effect that such legal decisions can have on financing relationships and especially on the incentives to reduce environmental risk in an environment where banks cannot commit to refinance the firm in all circumstances. Following an environmental accident, liable banks more readily agree to refinance the firm. We then show that bank liability effectively makes refinancing more attractive to banks, therefore improving the firm's risk-sharing possibilities. Consequently, the firm's incentives to invest in environmental risk reduction are weakened compared to the (bank) no-liability case. We also show that, when banks are liable, the firm invests at the full-commitment optimal level of risk reduction investment. If there are some externalities such that some damages cannot be accounted for, the socially efficient level of investment is greater than the privately optimal one. in that case, making banks non-liable can be socially desirable.

Environmental Risk: Should Banks Be Liable?

This paper studies the impact of banks' liability for environmental damages caused by their borrowers. Laws or court decisions that declare banks liable for environmental damages have two objectives : (1) finding someone to pay for the damages and (2) exerting a pressure on a firm's stakeholders to incite them to invest in environmental risk prevention. We study the effect that such legal decisions can have on financing relationships and especially on the incentives to reduce environmental risk in an environment where banks cannot commit to refinance the firm in all circumstances. Following an environmental accident, liable banks more readily agree to refinance the firm. We then show that bank liability effectively makes refinancing more attractive to banks, therefore improving the firm's risk-sharing possibilities. Consequently, the firm's incentives to invest in environmental risk reduction are weakened compared to the (bank) no-liability case. We also show that, when banks are liable, the firm invests at the full-commitment optimal level of risk reduction investment. If there are some externalities such that some damages cannot be accounted for, the socially efficient level of investment is greater than the privately optimal one. in that case, making banks non-liable can be socially desirable.