Regional Incentives and Patient Cross-Border Mobility: Evidence from the Italian Experience

Document Type : Original Article


1 Department of Economics and Finance, Università Cattolica del S. Cuore, Milano, Italy

2 Department of Economics, Law and Institutions, Università Tor Vergata, Roma, Italy


In recent years, accreditation of private hospitals followed by decentralisation of the Italian National Health Service (NHS) into 21 regional health systems has provided a good empirical ground for investigating the Tiebout principle of “voting with their feet”. We examine the infra-regional trade-off between greater patient choice (due to an increase in hospital services supply) and financial equilibrium, and we relate it to the significant phenomenon of Cross-Border Mobility (CBM) between Italian regions. Focusing on the rules supervising the financial agreements between regional authorities and providers of hospital care, we find incentives for private accredited providers in attracting patient inflows.
The analysis is undertaken from an institutional, regulatory and empirical perspective. We select a sample of five regions with higher positive CBM balance and we examine regional regulations governing the contractual agreements between purchasers and providers of hospital care. According to this sample, we provide a statistical analysis of CBM and apply a Regional Attraction Ability Index (RAAI), aimed at testing patient preferences for private/public accredited providers.
We find that this index is systematically higher for private providers, both in the case of distance/boundary patients and of  excellence/general hospitals.
Conclusions address both financial issues regarding the coverage of regional healthcare systems and equity issues on patient healthcare access. They also raise concerns on the new European Union (EU) directive inherent to patient mobility across Europe.


Commentaries Published on this Paper

  • Interregional Patient Mobility in the Italian NHS: A Case of Badly-Managed Decentralization; Comment on “Regional Incentives and Patient Cross-Border Mobility: Evidence From the Italian Experience”     

            Abstract | PDF

  • Is It More Important to Address the Issue of Patient Mobility or to Guarantee Universal Health Coverage in Europe?; Comment on “Regional Incentives and Patient Cross-Border Mobility: Evidence From the Italian Experience”     

            Abstract | PDF

  • The Health Mobility Is All True Mobility?; Comment on “Regional Incentives and Patient Cross-border Mobility: Evidence From the Italian Experience”  

            Abstract | PDF


Author’s Response to the Commentaries

  • Cross-Border Mobility in Italy: Some Considerations in Response to the Recent Commentaries

            Abstract | PDF


Main Subjects

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  1. Le Grand J, Mays N, Mulligan J. Learning from the NHS Internal Market: A Review of the Evidence. London: Kings Fund; 1998.
  2. Cellini R, Pignataro G, Rizzo I. Competition and efficiency in health care: an analysis of the Italian case. International Tax and Public Finance 2000; 7: 503-19. doi: 10.1023/A:100873750656
  3. Propper C, Burgess S, Green K. Does competition between hospitals improve the quality of care? Hospital death rates and the NHS internal market. J Public Econ 2004; 88: 1247-72. doi: 10.1016/S0047-2727(02)00216-5
  4. Fredriksson M, Blomqvist P, Winblad U. The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice. J Eur Soc Policy 2012; 23: 192-209.
  5. Neri S. The Structuring of Regional Health Services and the Governance of the Health System. The Italian Journal of Social Policy 2008; 3: 97-114.
  6. Fattore G. Traveling for care: Inter-regional mobility for aortic valve substitution in Italy. Health Policy 2010; 117: 90-7. doi: 10.1016/j.healthpol.2014.03.002
  7. Bruzzi S. Health care regionalisation and patient mobility: the challenges for a sustainable Italian Health Service. Jean Monnet Interregional Centre of Excellence, University of Pavia; 2012.
  8. Del Bufalo P. Mobility, maxi deficit in the South. Il Sole 24 Ore Sanità; 13-19.11.2012. Available from:
  9. Del Bufalo P. North of Italy, cradle of high specialty. Il Sole 24 Ore Sanità; 16-22.4.2013.  Available from:
  10. Balia S, Brau R, Marrocu E. Free patient mobility is not a free lunch. Lessons from a decentralized NHS. Working paper No. 09; 2014. Available from:
  11. Levaggi R, Zanola R. Patients’ migration across regions: the case of Italy. Appl Econ 2004; 36: 1751-7. doi: 10.1080/0003684042000227903
  12. Cantarero D. Health care and patients’ migration across Spanish regions. Eur J Health Econ 2006; 7:  114-6. doi: 10.1007/s10198-006-0341-6
  13. Fabbri D, Robone S. The geography of hospital admission in a National Health Service with patient choice. Health Econ 2010; 19: 1029-47. doi: 10.1002/hec.1639
  14. Glinos IA, Baeten R, Helbe M, Maarse H. A typology of cross border mobility. Health Place 2010; 16: 1145-55. doi: 10.1016/j.healthplace.2010.08.001
  15. Sciattella P, Spandonaro F. Mobilità dei ricoveri, elementi di complessità e incentivi delle politiche sanitarie. Monitor 2012; 29: 84-95.
  16. Exworthy M, Peckham  S. Access, choice and travel: implication for health policy. Soc Policy Adm  2006; 40: 267-87. doi: 10.1111/j.1467-9515.2006.00489.x
  17. Glinos I, Doering N, Maarse H. Travelling home for treatment and EU patients’ right to care abroad: results of a survey among German students at Mastricht University. Health Policy 2012; 105: 38-45. doi: 10.1016/j.healthpol.2011.12
  18. Lunt N, Mannion R, Exworthy M. A framework for exploring the policy implication of UK Medical Tourism and international patient flows. Soc Policy Adm 2013; 47: 1-25. doi: 10.1111/j.1467-9515.2011.00833.x
  19. Lunt N, Mannion R. Patient mobility in the global marketplace: a multidisciplinary perspective. Int J Health Policy Manag 2014; 14; 2: 155-7. doi: 10.15171/ijhpm.2014.47
  20. Bustamante AV. Globalization and medical tourism: the North American experience. Int J Health Policy Manag 2014; 3: 47-9. doi: 10.15171/ijhpm.2014.57
  21. Tiebout C. A pure theory of local expenditures. J Polit Econ 1956; 64: 416-24.
  22. Italian Ministry of Health [homaoage on the internet]. Available from:
  23. France G, Taroni F, Donatini A. The Italian health-care system. Health Econ 2005; 14: S187–202. doi: 10.1002/hec.1035
  24. Brenna, E. Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy. Health Policy 2011; 103: 209-18. doi: 10.1016/j.healthpol.2011.10.003
  25. Maino F, Neri S. Explaining welfare reforms in italy between economy and politics: external constraints and endogenous dynamics. Soc Policy Adm 2011; 45: 445-64. doi: 10.1111/j.1467-9515.2011.00784.x
  26. Bordignon M, Boeri T. Il federalismo? Meglio se a velocità variabile [internet]. 2010. Available from:
  27. Brenna E. The Local Health Authorities’ role in managing  hospital expenses: empirical findings from  the Local Health Authority of Como. Sanità Pubblica e Privata 2007; 6: 39-49. Available from:
  28. Caroppo MS, Turati G. The Italian regional health care systems. Vita e Pensiero ed; 2007.
  29. Cantù E, Ferrè F, Sicilia M. Regions and private accredited health firms, the possible managing strategies. Rapporto OASI Cergas Bocconi; 2011.
  30. Le Grand J. Competition, cooperation, or control? Tales from the British National Health Service. Health Aff (Millwood) 1999; 18: 27-39. doi: 10.1377/hlthaff.18.3.27
  31. Centre for Market and Public Organisation (CMPO). Hospital care in England: who will choose? Research in Public Policy. University of Bristol; 2007. Available from: