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A Guided Tour on research in Health Economics and its relevance for the Health A Guided Tour on research in Health Economics and its relevance for the Health Policy Agenda Prof. Guillem López-Casasnovas Depart. of Economics Univ. Pompeu Fabra.

intro n HEALTH ECONOMICS AS A A DISCIPLINE: ECONOMICS!!!! n HEALTH ECONOMICS AS A intro n HEALTH ECONOMICS AS A A DISCIPLINE: ECONOMICS!!!! n HEALTH ECONOMICS AS A RESEARCH AREA: WIDE SCOPE WITH THE ADDED VALUE OF INTERDISCIPLINARITY… 2

A B WHAT INFLUENCES HEALTH? (OTHER THAN HEALTH CARE) Occupational hazards; consumption patterns; Education; A B WHAT INFLUENCES HEALTH? (OTHER THAN HEALTH CARE) Occupational hazards; consumption patterns; Education; Income etc WHAT IS HEALTH? WHAT IS ITS VALUE? Perceived attributes of health; health status indexes; value of life; utility scaling of health E F C MICRO-ECONOMIC EVALUATION AT TREATMENT LEVEL Cost effectiveness & cost benefit analysis of alternative ways of delivering care (e. g. choice of mode, place, timing or amount) at all phases (detection, diagnosis, treatment, after care etc. ) MARKET EQUILIBRIUM Money prices, time prices, waiting lists & nonprice rationing systems as equilibrating mechanisms and their differential effects DEMAND FOR HEALTH CARE Influences of A + B on health care seeking behaviour; barriers to access (price, time, psychological, formal); agency relationship; need D SUPPLY OF HEALTH CARE Costs of production; alternative production techniques; input substitution; markets for inputs (workforce, equipment, drugs etc. ); remuneration methods and incentives H PLANNING, BUDGETING & MONITORING MECHANISMS Evaluation of effectiveness of instruments available for optimising the system; including the interplay of budgeting, workforce allocations; norms; regulation etc. and the incentive structures they generate. G EVALUATION AT WHOLE SYSTEM LEVEL Equity & allocative efficiency criteria brought to bear on E + F; interregional & international comparisons of performance 3

in the research-frontier agenda under the Williams’ frame of the discipline areas… n ‘A’ in the research-frontier agenda under the Williams’ frame of the discipline areas… n ‘A’ area: Grossman’s demand for health in the HK tradition, expanded at the macro level by reframing the neoclassical production function n ‘B’ area: QALY common ground analysis – Psychometrics at the micro – Time series analysis for the value of health at the macro level (controlling for exogenous factors other than health care!!) 4

. . . in the research-frontier agenda n ‘C’ area: demand for health care, . . . in the research-frontier agenda n ‘C’ area: demand for health care, under uncertainty (ie. Insurance). Premia (actuarilly fair), prices, copayments, deductibles. The Rand experiment (70 s!). Models of principal-agent relationship, moral hazard (HSAs in the policy arena), explaining waiting lists. . . n ‘D’ area: supply -induces demand: how many doctors, professional incentives, team production (and free riding), productivity, pay performance, variation in clinical practice, ‘moonlighting’. . . 5

. . . in the research-frontier agenda n ‘E’ area: public intervention in health . . . in the research-frontier agenda n ‘E’ area: public intervention in health care: ‘welfarists’ against ‘non-welfarists’. Eliciting preferences (eg. Conjoint analysis) vs. willingness to pay models. Plus cost analysis, bayesian approach to economic evaluation, prioritisation. . . n ‘F’ area: markets in health care (information theory, uncertainty), third party payment systems, optimal rate setting (semi-parametric cost frontier analysis) and optimal risk pooling, efficient prices (‘blending’ prospective and retrospective), risk adjustment techniques for risk selection avoidance. . 6

. . . in the research-frontier agenda n ‘G’ area: Global system evaluation in . . . in the research-frontier agenda n ‘G’ area: Global system evaluation in the public health tradition + WB + WHO + EQUTY project + global burden of disease impacts + analysis on how to combine public and private (insurance) systems. . . Under policy evaluation techniques ‘matching samples’, double and triple difference in difference models. . . n ‘H’ area: in the NHS tradition, Markov’s models, simulation techniques for changed scenarios, needs estimation, normative standarisation of utilisation, political devolution, the provision-production split, the Health System Integration Study, coordination in health care delivery, the optimal decentralisation and risk transfer to providers, rol for private care in public health 7 systems. . .

I. - Health Economics is ‘what health economists do’ n Some selected 2007 & I. - Health Economics is ‘what health economists do’ n Some selected 2007 & 2008 papers for the Arrow’s Award 8

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Bleakley, QJE n Paradigmatical evaluation of a public policy (before/after type) under rich longitudinal Bleakley, QJE n Paradigmatical evaluation of a public policy (before/after type) under rich longitudinal pannel data regression analysis, under Indirect Least Sqares plus subsampling and comparison of methods. Assessing the social externalities derived from the hookworm eradication programme 10

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Chandra & Staiger, JPE n Mostly theory oriented contribution. In the empirical part the Chandra & Staiger, JPE n Mostly theory oriented contribution. In the empirical part the paper argues against the flat of the curve hypothesis in myordial surgery. It accounts for the potential biased selection effect (surgery for those with a higher likelihood of recovery) that biases OLS. It uses instrumental variable methods after some initial logits on the cardio illness probability 12

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Das & Hammer, J Devel Econom n Geographical dual practice possibilities and/or biased selection Das & Hammer, J Devel Econom n Geographical dual practice possibilities and/or biased selection public/private physicians’ employment choice may be a problem. The paper follows a matching propensity score approach, sorting by income, patient characteristics, location, etc. It compares non lineal probit results with OLS. 14

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Finkelstein, QJE n Generalized linear model, weighted and unweighted OLS. Estimation, trend actual residual Finkelstein, QJE n Generalized linear model, weighted and unweighted OLS. Estimation, trend actual residual (before and after type) since the introduction of Medicare on health care insurance and on a full range of affected variables. . . 16

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Fishback et al. Rev of Econom & Statistics n Searching for the relief costs Fishback et al. Rev of Econom & Statistics n Searching for the relief costs of the lifes saved by the program. Micro panel data for understanding the effects of the great depression: OLS, OLS with fixed effects ands 2 SLS with fixed effects 18

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Glazer et al. JHE n Pure theoretical contribution (Game Theory) 20 Glazer et al. JHE n Pure theoretical contribution (Game Theory) 20

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Hall & Jones QJE n Theory Model calibration Numerical results in valuing how marginal Hall & Jones QJE n Theory Model calibration Numerical results in valuing how marginal utility of extending life increases, and not decline, with rising incomes 22

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Iizuka, Rand Journal n Mc Fadden standard nested logit- share equation, on how physicians Iizuka, Rand Journal n Mc Fadden standard nested logit- share equation, on how physicians mark up the prescribed drugs. Nested logit models with/without instrumental variables plus random coefficients with instrumental variables. 24

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Avery et al. JPE n Dealing with the reverse causality problem between advertising and Avery et al. JPE n Dealing with the reverse causality problem between advertising and consumption Instrumental variables approach, OLS and linear probability models. 26

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Biglaiser & Ma Rand Journal n Pure theoretical contribution 28 Biglaiser & Ma Rand Journal n Pure theoretical contribution 28

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Acemolglu & Finkelstein, JPE n Mostly theoretical plus time series analysis on how hospitals Acemolglu & Finkelstein, JPE n Mostly theoretical plus time series analysis on how hospitals react to changes. Censored data estimation between those who adopt and who does not technological changes 30

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Aldi & Viscusi, Rev of Econom & Statistics n Adjusting the value of the Aldi & Viscusi, Rev of Econom & Statistics n Adjusting the value of the statistical life for age and cohort effects. Observing the wage/ risk trade-offs. Age specific regression analysis of hedonic wages, extended to a two stage minimum distance estimator. Data pooling in order to control for the birth-cohort effect. 32

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Brown & Finkelstein, AER n Estimation of the crowding-out effect between public and private Brown & Finkelstein, AER n Estimation of the crowding-out effect between public and private programs for health insurance Medicaid and Long Term Care. Model calibration and numerical simulation of the before and after type 34

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Card et al. , AER n Time series analysis from rich micro data on Card et al. , AER n Time series analysis from rich micro data on the impact of the Medicare implementation on the utilization of health care services. Before and after comparison once having adjusted for hospital diversity and several other interactions. 36

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Fang et al. , JPE n Testing advantageous selection: whether risk averters are ‘cookies’: Fang et al. , JPE n Testing advantageous selection: whether risk averters are ‘cookies’: they insure more and utilize less. Why and how. Rich data set very much worked with, two micro panel and OLS estimation. 38

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Leonard, JHE n Random effects logit regression, since among the observations some physicians without Leonard, JHE n Random effects logit regression, since among the observations some physicians without changes in the patients’ satisfaction. Comparing this with fixed effects estimation for those with variation of patients’ satifation versus utilizing random effects for all the sample. Haussman test for the difference. 40

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Martin et al. , JHE n On the potential endogeneity of health care spending Martin et al. , JHE n On the potential endogeneity of health care spending on health programs (money flows where health problems exist, and resources tend to correct them). Tackling the problem by Instrumental variables and two stage least squares. Testing the validity of several instruments. 42

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Van Houtven & Norton, JHE n Testing the effects of heterogeneous informal care treatments Van Houtven & Norton, JHE n Testing the effects of heterogeneous informal care treatments on Medicare expenses. Two part expenditure model according to the type of informal home care, once controlling for endogeneity through instrumental variables (since formal and informal care mostly interdependent but only formal care impacts on spending). Since 2 SLS standard structure is inconsistent in controlling for endogeneity, they adopt two stage residual inclusion and for the discrete outcomes, a probit for instrumental variables. 44

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Yin, JHE Panel data and a difference-in-difference approach for orphan drugs and others, since Yin, JHE Panel data and a difference-in-difference approach for orphan drugs and others, since orphans are subject to a different set of incentives. Testing the effectiveness of these incentives in terms of actual pharmaceutical innovation 46

GENERAL THEORETICAL TREND GROWING ANALYTICAL SOPHISTICATION n USA DOMINATES n PUBLIC HEALTH EXTERNALITIES WITH GENERAL THEORETICAL TREND GROWING ANALYTICAL SOPHISTICATION n USA DOMINATES n PUBLIC HEALTH EXTERNALITIES WITH RENEWED INTEREST n MACRO: HEALTH VALUE GAINS n MICRO: CLINICAL PRACTICE AND INCENTIVES n 47

GENERAL THEORETICAL TREND INSURANCE, MORAL HAZARD & COSTS n LESS ON CBA OR CEA GENERAL THEORETICAL TREND INSURANCE, MORAL HAZARD & COSTS n LESS ON CBA OR CEA n PROVIDERS SUPPLY/ DEMAND OF HEALTH CARE VERY MUCH SENSITIVE TO THE ESPECIFICITY OF THE HEALTH SYSTEMS FOR EXTRAPOLATING RESULTS n 48

GENERAL EMPIRICAL TREND REGRESSION ANALYSIS BEFORE AND AFTER TYPE n INSTRUMENTAL VARIABLES FOR ENDOGENEITY GENERAL EMPIRICAL TREND REGRESSION ANALYSIS BEFORE AND AFTER TYPE n INSTRUMENTAL VARIABLES FOR ENDOGENEITY n DIFFICULTY IN TESTING THE DIRECTION OF THE REVERSE CAUSALITY HYPOTHESIS n RICH LONGITUDINA, MICRO, PANEL DATA. n 49

GENERAL POLICY CONCERNS: IN n n INTERACTIONS PUBLIC/ PRIVATE INSURANCE EXTERNALITIES AND ECONOMIC DEVELOPMENT GENERAL POLICY CONCERNS: IN n n INTERACTIONS PUBLIC/ PRIVATE INSURANCE EXTERNALITIES AND ECONOMIC DEVELOPMENT EFFECTS FROM PUBLIC HEALTH INTERVENTIONS STRATEGIC ORGANISATIONAL DESIGN FOR HEALTH: THE INCENTIVE COMPATIBILITY FRAME RISK SELECTION AND ADVERSE SELECTION IN INSURANCE 50

GENERAL POLICY CONCERNS: OUT OF THE ANALYSIS FINANCIAL SUSTAINABILITY n CHANGES IN SUPPLY OF GENERAL POLICY CONCERNS: OUT OF THE ANALYSIS FINANCIAL SUSTAINABILITY n CHANGES IN SUPPLY OF HEALTH CARE n THE CONTRIBUTION OF HEALTH CARE TO HEALTH (QALY, HYE…) n OPTIMAL RISK POOLING n COST EFFECTIVENESSA ANALYSIS AND PRIORITY SETTING n 51

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n ADDENDA: FOOD FOR THOUGHT 53 n ADDENDA: FOOD FOR THOUGHT 53

HEALTH SYSTEMS: “The Health Care Box” COLLECTING ORGANISATION: Country/regional, Social Security Mutual Funds, Private, HEALTH SYSTEMS: “The Health Care Box” COLLECTING ORGANISATION: Country/regional, Social Security Mutual Funds, Private, HMOs m tu en ex tilis t te at nt io n FINANCIAL MECHANISM: Taxes (direct/indirect), pay-roll Savings, fees, premia C op ay SOURCE: Employer, employees Tax payers, users Population coverage (breadth) Restricted / Universal vi field Se r ility Eligib ce s C Sc ur o e/ pe C ar (d e e pt h) C os PUBLICLY PROVIDED HEALTH EXPENDITURE OVER GDP 54 Modified from Busse R, et al (Feb 2007) HNP “Analyzing changes in Health Financing Arrangements in High-Income Countries

…The options • The frameworks of health care organisation and finance n Planning/ Finance/ …The options • The frameworks of health care organisation and finance n Planning/ Finance/ Insurance Risk management/Purchasing Production of care n Health and Finance Depart. /Health Insurance Agencies / Purchasers of care services /Production and Managerial Units 55

STRATEGIC MANAGEMENT DESIGN (HAX, MAJLUF) Planning System Control System Information System Financing System ORGANISATIONAL STRATEGIC MANAGEMENT DESIGN (HAX, MAJLUF) Planning System Control System Information System Financing System ORGANISATIONAL CULTURE COST CENTERS / RESPONSIBILITY CENTERS 57

THE FINANCIAL RISK TRANSFER FROM PAYERS TO PROVIDERS: (AVERHILL, 2003) 58 THE FINANCIAL RISK TRANSFER FROM PAYERS TO PROVIDERS: (AVERHILL, 2003) 58

2. - Some research-frontier issues in the specific Health Policy agenda n n n 2. - Some research-frontier issues in the specific Health Policy agenda n n n THE VALUE OF HEALTH : Wagner (health spending and GDP)-Engel (public/private mix) – Preston (flat part of the curve and public taxation) THE CONTRIBUTION OF HEALTH CARE TO HEALTH: priority setting; incremental CEA, shadow Qaly value; non-optimal substitute (opportunity) costs; ‘appraising’ and ‘assessing’ health care; budget rigidities in health care management HEALTH SYSTEMS ORGANISATION AND HEALTH CARE MANAGEMENT: NHS vs SHIS 59

Life Expectancy in Years Gains in Health by Income Levels 1900, 30 s, 60 Life Expectancy in Years Gains in Health by Income Levels 1900, 30 s, 60 s, 2000 s (A. Preker, WB. , 2004) 80 About 1960 70 About 1930 60 About 1900 50 Reverse Development Process in the future? 40 30 0 5, 000 10, 000 15, 000 20, 000 Income per capita (at 1991 Dollars) and postulated health related expenditure 25, 000 60

THE CONTROVERSIAL CONTRIBUTION OF HEALTH CARE TO HEALTH Uncertainty of health care treatments: to THE CONTROVERSIAL CONTRIBUTION OF HEALTH CARE TO HEALTH Uncertainty of health care treatments: to whom (cohort, age, gender) and under which conditions (comorbidities. . )

Some ‘hot’ issues in Health Policy n On health valuation: – to what extent Some ‘hot’ issues in Health Policy n On health valuation: – to what extent are getting aggregate good value for money in health care; different patterns for Develop. vs. LDCs – differences in sub-group valuations and its effects on implementing (delivering and financing) routine health care n On prioritisation: – – n where to fix the cut off (in & out of the public coverage)? E. g. £ 15000 or £ 30000 per Quality Adjusted Life Year? Distributional issues: – equal weighting of benefits or equity weighting? 62

The Health Care ‘Industry’ 1. Catastrophic coverage (insurance) n 2. Incentives for preventive services The Health Care ‘Industry’ 1. Catastrophic coverage (insurance) n 2. Incentives for preventive services (public health) n 3. Efficient pricing- rate setting (purchasing) n 4. Welfare maximand (allocation and redistribution policies) n 63

Too much work to be bored… THANKS FOR YOUR ATTENTION!!! n Addenda… 64 Too much work to be bored… THANKS FOR YOUR ATTENTION!!! n Addenda… 64

THE HEALTH CARE DELIVERY SYSTEMS n National Health Service- Social Health Care Systems 65 THE HEALTH CARE DELIVERY SYSTEMS n National Health Service- Social Health Care Systems 65

…HOW HEALTH CARE BOXES, MAINLY THOSE IN PUBLIC SYSTEMS, GET ADJUSTED n FOR GREATER …HOW HEALTH CARE BOXES, MAINLY THOSE IN PUBLIC SYSTEMS, GET ADJUSTED n FOR GREATER MANAGEABILITY, PORTABILITY (INNOVATION AND ADJUSTMENT TO NEW SOCIAL NEEDS) AND ASSURING THEIR FINANCIAL SUSTAINABILITY… n HOW -BY CHANGING THE HEALTH CARE BOXES-, THE NATIONAL HEALTH SERVICES AND THE SOCIAL HEALTH INSURANCE SYSTEMS ANSWER TO THE NEW CHALLENGES: DEMOGRAPHICS, TECHNOLOGY CHANGES AND CONCERNS FOR EQUITABLE ACCESS TO CARE 66

THE ANALYSIS: . . . the departing point: the nature of the systems • THE ANALYSIS: . . . the departing point: the nature of the systems • The ‘NHS’: ‘NATIONAL’ (aiming to geographical-universal uniform access conditions) ‘HEALTH’ (through an intersectional coordinated action) ‘SERVICE’ (by state administered care). • However: diversity at the point of access is unavoidable (not much contribution to reduce health inequalities in the English NHS–Le Grand); corporative interests of health care providers, rather than health targets, usually prevail; and some care services prove unmanageable in political hands (difficulty to say ‘no’, lack of commitment) 67

 • To minorate these problems NHS have moved to the provision/ production split, • To minorate these problems NHS have moved to the provision/ production split, with DECENTRALISATION in order to improve efficiency (by transferring responsibilities to providers) and assure that, if inequalities, they are ‘acceptable’ (by choice or being local communities financially accountable after the central levelling of resources) 68

NHS’ SYSTEM INCENTIVES for improvement: For coordination in delivering care (fund-holding on a capitation NHS’ SYSTEM INCENTIVES for improvement: For coordination in delivering care (fund-holding on a capitation risk- adjusted basis), mostly centred in primary care management of illnesses (LTCs, Chronic care conditions…) and paying for health outcomes performed. New roles for the private sector: Public-private partnerships, internal markets in providing public services, opening complementary private finance for less cost effective care, once excluded from the public packages 69

. . . the departing point: the nature of the systems. THE SOCIAL HEALTH . . . the departing point: the nature of the systems. THE SOCIAL HEALTH CARE INSURANCE SYSTEMS: ‘Social’ (community –solidarity- premia); ‘Health Care’ (life cycle utilization of affiliates); ‘Insurance’ (risk pooling, entitlements of coverage); ‘System’ (networks of multiple independent providers). However: Sustainability implies to restrain open access, favoring primary care gate keeping for the delivery of care and a more accurate screening of the basic package granted for collective compulsory finance. 70

To minorate these problems SHIS have moved towards RISK TRANSFER from insurers to affiliates To minorate these problems SHIS have moved towards RISK TRANSFER from insurers to affiliates (copayments, deductibles. . ) and providers (riskrating, prospective case-mix payments, global budgeting…) INCENTIVES FOR COORDINATION by inserting into the system new ‘brokers’ of the individuals’ care and lower co-payments to users if they access the system through primary care NEW STRATEGIES IN MANAGING ILLNESS EPISODES, being more selective in what services are ‘in’ and ‘out’ in the former comprehensive package of services 71

BASIC NHS- SHIS: DIFFERENCES: 1 -Degree of choice between cash transfers versus in -kind BASIC NHS- SHIS: DIFFERENCES: 1 -Degree of choice between cash transfers versus in -kind delivery of care 2 -Political involvement still in the public provision/private production split

NHS- SHIS: DIFFERENCES: 3 - Scope and actual mix of health care coverage: On NHS- SHIS: DIFFERENCES: 3 - Scope and actual mix of health care coverage: On basic (tax financed), complementary (tax- favoured, under regulated community premia) and additional (private) package of services. With limited opting-out 4 -On the way they allocate the health care management roles and its finance: The flow of Funds

“NHS type” Flow of funds District Health Authorities Public Funder (Capitation risk adjusted) Hospital “NHS type” Flow of funds District Health Authorities Public Funder (Capitation risk adjusted) Hospital Care e vic Primary Care s r Se Citizens / tax payers Se e vic s r Services Fund. Holders or Integrated Providers (Trusts) Inpatient care

“SHIS type” Flow of funds Health Insurer Providers in su en t ta en “SHIS type” Flow of funds Health Insurer Providers in su en t ta en em pl m Co Citizens / premia s e ric P ry ym pa Co Basic package s ra nc e Public Funder Se e vic r s

ARGUMENTS FOR ASSESSING THE SUPERIORITY OF EACH MODEL: INCENTIVES TO PROVIDERS FOR AN EFFICIENT ARGUMENTS FOR ASSESSING THE SUPERIORITY OF EACH MODEL: INCENTIVES TO PROVIDERS FOR AN EFFICIENT AND EQUITABLE DELIVERY COMPATIBLE WITH CONSUMERS’ CHOICE STRATEGIES FOR REDUCING MORAL HAZARD IN HEALTH CARE CONSUMPTION, HOLDING EQUITABLE OUTCOMES THE EFFECTIVENESS OF IN-KIND VERSUS CASH TRANSFERS IN ACHIEVING POPULATION HEALTH TARGETS

COMMON GROUNDS IN BOTH SYSTEMS • Which part of the coverage should be under COMMON GROUNDS IN BOTH SYSTEMS • Which part of the coverage should be under public regulation and collective finance: less predictable, more financially catastrophic… • How to decentralise responsibilities: minimum risk-pooling for a credible financial transfer and competition by improving providers’ autonomy: the options 77

PRIVATE- PUBLIC RELATIONSHIPS IN HEALTH CARE ON THE INSURANCE SIDE: • ALTERNATIVE • COEXISTING PRIVATE- PUBLIC RELATIONSHIPS IN HEALTH CARE ON THE INSURANCE SIDE: • ALTERNATIVE • COEXISTING (THE COMPATIBILITY OF PRACTICES ISSUE), • COMPLEMENTARITY RELATIONS (TAKING MUTUAL ADVANTAGE) • SUPPLEMENTARY (ON THE TOP, WHERE IT DOES NOT REACH. . ) ON THE PROVIDER SIDE: PRIVATE HEALTH CARE ‘IN’ AND ‘OUT’ OF PUBLIC FACILITIES ON THE FINANCING SIDE: PUBLIC PRIVATE PARTNERSHIPS