Efficiency Frontiers in Treating Lifestyle Diseases

Abstract Research background: Following a rational health policy by the state is tantamount to having knowledge of society’s health status and health affecting factors. It has become particularly important to focus on the 21st century diseases resulting in premature deaths. That objective dominated the 2016 Act on Public Health and the 2016–2020 National Health Programme connected with it. Purpose: The aim of the paper is to present the results of an analysis concerning hospitals’ technical efficiency assessment in treating diseases of civilization in Poland by provinces. A BCC model with a changing effects of scale and the DEA method were applied, using linear programming. Results: The received results of assessing the technical efficiency of patient treatment related to diseases of civilization from the temporal and spatial point of view may serve as a basis for decisions on regional policy creation. Novelty: Interest in measuring production factors of healthcare activity and outcomes may be ascribed to increased care about costs borne in the sector and pressure on responsible management in the public sphere. Thus, planning appropriate actions aimed at maintaining and improving public health leads to the rational use of funds and improved lives of the population.


Introduction
The healthcare status of citizens in Poland is becoming increasingly important in both carrying out state health policy and individual citizens' decisions. The healthcare system in Poland, as an insurance and budget based one with a substantial role of the payer (the National Health Fund), covers the costs of health services and checks how money is expended. The insured may use health services rendered by public or private healthcare providers. Healthcare system reforms come down to seeking the most efficient system which would ensure healthcare to the largest possible part of the population using the least possible financial means while maintaining a certain treatment standard. According to GUS = CSO publications, the population situation of Poland remains difficult, as no significant changes guaranteeing stable demographic development can be expected in the near future. This results in low fertility and births, while extending life expectancy. The share of the oldest group in the general population is increasing significantly, so we are observing a faster aging of the population. Comparing the median age of deceased in 2018 of 77 years (71 years for men and 82 years for women) with the median age of deceased in 2000 of 73 years (69 years for men and 78 years for women) we can conclude that we are living longer but the main causes of death are cardiovascular disease and cancer, i.e. lifestyle diseases.
Thus, population treatment has not only a humanitarian value but also a specific macroeconomic dimension. Problems entailed by unemployment in Poland translated indirectly into reducing financial means flowing in the form of health contributions to the NHF as the main disposer of pecuniary means in healthcare financing. In recent years, an improved economic situation has positively affected the labour market, hence also increasing the inflow of health contributions to the NHF. However, financial needs related to healthcare are growing as modern medicine and pharmacology are becoming more and more expensive. Elderly people are using health services and reimbursed pharmacology to an increasing extent, which makes their lives longer, and at the same time it increases financial expenses for health care (Wojtyniak, Goryński, 2016). Lifestyle diseases are becoming more and more common among younger and younger generations, which also leads to rising healthcare costs (Kowalczuk, Krajewska-Kułak, Cybulski, 2016). Therefore, numerous questions arise regarding the demand for health services in treating diseases, its financing and efficient use of available resources.
An essential element of social security in the healthcare system is to ensure the greatest possible access to publicly financed health services to all entitled individuals so that financing can take place applying the national income redistribution principle. What is crucial is to utilise public means meant for healthcare in as rational a way as possible.
In order to improve and protect the health of society, the National Health Programmes (NHPs)  The Ministry of Health coordinates actions aimed at improving population health and resolving discrepancies based on the cooperation of the government, local self-governments and non-governmental organisations. Particular attention is paid to protecting and shaping the environment we live in and health promotion defined as a process enabling people to have more control over their health through making choices and decisions beneficial to health (Kowalewski, 2010). An individual's lifestyle determines his or her health maintenance to the largest extent. Politicians, the state and local administration as well as non-governmental organisations may influence health policy development by creating favourable conditions for people to make choices beneficial to their health and increasing their awareness in that scope. Moreover, innovative Medical Centres are being set up dealing with lifestyle diseases' prevention subsidised from EU funds (Menedżer Zdrowia, July 2017).
Conducted regional research into the population health status shows social and territorial differences and the fact that poorer health occurs in the uneducated, indigent and unemployed.
Thus, the main aim of the present NHP is to improve health and associated life quality of the population and reduce inequalities in health through using various instruments, particularly financial ones supporting families.
Repair changes have been introduced in the health sector many a time, but so far they have not significantly increased the efficiency or effectiveness of Polish healthcare (Jaworzyńska, Rozpędowska-Matraszek, Cholewa-Wiktor, 2017). At the present world development stage, the market constitutes the most effective method of management.
Economic entities operating in market economy conditions, also in the healthcare sector, rely on the efficient management of possessed resources; growing competition forces them to incessantly improve the efficiency of their operations (Ćwiąkała-Małys, Nowak, 2009).
Market mechanisms are difficult to apply to the efficient financing of social services with the reservation that service distribution among citizens should be determined by social rather than market considerations. The inefficiency problem occurs in every country, with principal differences lying in how well particular systems are able to limit that (Waller, Gotway, 2004), (Folland, Goodman, Stano, 2010). An efficient organisation needs both stability and openness to development and change (Frączkiewicz-Wronka, 2010).
Efficiency research is a fundamental element of the decision-making process whose aim is to maximise obtained outputs. The notion of efficiency is most commonly equated with its economic character, focusing mainly on two aspects, i.e. the technological and costrelated ones (Morris, Delin, Parkin, 2007). WHO experts estimate that 20-40% of healthcare expenditures, on average, are inappropriately used, hence it is worth giving attention to the problem of inefficiency.
The principles of economic efficiency theory in perfect competition conditions were formulated by Italian economist Pareto. Along with the perfect competition model, economic theory and practice apply various economic efficiency measures depending on what is assumed as the input and output. Thus, various efficiency relationships are received. Efficiency research covers activity outputs produced at specified inputs or deal with utilising inputs that allows generating assumed outputs. Samuelson and Nordhaus claimed that efficiency may be the main subject of economics; it is the absence of wastage.
Achieving economic efficiency by an entity is associated, among others, with technical efficiency. According to J. Suchecka (2009), technical efficiency consists in equalising the marginal costs of producers of a given type of production. Costs are determined by price levels established in the market play process. In health economics, technical efficiency is defined as an output of hospital service activity related to providing services at a specified time and utilising specified inputs. Efficiency assessment, therefore, is associated with determining an appropriate combination of factors that allow maximising the enterprise activity output. In general, efficiency measurement methods may be divided into three major groups, i.e. index, parametric and non-parametric. Non-parametric methods are employed to measure the technical efficiency of enterprises rendering health services and enable analysing inputs and outputs (Vincova, 2005).
Since 1978, numerous publications have occurred related to methodological principles reflecting DEA method development. Articles and studies on the application of the method in various research areas and sectors, both public and private ones, have been published.
Healthcare entity efficiency research employing frontier methods was proposed, among others, by R.D. Banker, R.F. Conrad and R. Strauss (1986), J.L. Fizel and T.S. Nunnikhoven (1992), as well as P. Kooreman (1994). The utility of the DEA method in analysing medical service provider efficiency was presented by A. Worthington (2004). The DEA method was utilised in many ways in analyses of non-for-profit organisations, which include healthcare (Chen, Hwang, Shao, 2005;Hajialiafzali, Moss, Mahmood, 2007). Issues connected with defining and measuring efficiency were presented by (Kisielewska, 2008), (Rutkowska, 2013). Examples of DEA method applications to the health system in Polish efficiency studies were used by (Folland et al., 2010;Kozuń-Cieślak, 2011;Jewczak, Żółtaszek, 2011;Jacobs, Smith, Street, 2006). The DEA method was employed by A. Wierzbicka (2017) to assess the technical efficiency of traumatology and orthopaedic surgery departments, and a team of researchers (Ni Luasa, Dineen, Zieba, 2018) used the DEA method to assess technical performance in public and private Irish nursing homes. There are more and more healthcare entities (including hospitals) in Poland where optimising steps are implemented, while economic results show that carrying out the patient-focused mission may be reconciled with maintaining profitability. That has contributed to applying the method in practice in the analysis of hospital treatment efficiency related to treating lifestyle diseases in the cross-section of provinces, Menedżer Zdrowia (Issues 4-5/2018).
The aim of the analysis is to present results of the technical efficiency assessment of hospital treatment in the scope of treating lifestyle diseases in Poland according to provinces using the frontier data method. An attempt was made at assessing identical access to hospital treatment in provinces despite their different levels of economic development. A question was posed whether it is possible to maintain hospital treatment efficiency through input reduction.

Research Method
Health has become an element of economic calculation and measurement of relationships between provided inputs and produced outputs. The operation of healthcare entities in competitiveness conditions is extremely difficult; hence seeking solutions related to financial savings in their activity is advisable. A non-parametric method was employed for measuring the technical efficiency of operations, which allows analysing inputs and outputs and determining an inefficiency frontier.
Developed by A. Charnes, W.W. Cooper and E.L. Rhodes (1978), the DEA method has been used in many applications as it does not require determining the functional relationship between inputs and outputs. It allows simultaneously considering many inputs and many outputs of a decision-making unit. Thanks to the method, efficient and inefficient units can be identified.
The method can be used to establish specific inefficiencies, which may be unidentifiable applying other analytical instruments such as linear regression or index analysis. The same characteristics make the DEA method to be regarded as a good tool, which, however, may also pose problems. The DEA method is a frontier technique, hence disruptions in the form of a measurement error may lead to wrong decisions and data accuracy in analyses in examining a unit's efficiency is of extreme importance. The method merely indicates the achievements of a given unit in comparison to other units in a sample rather than compared to a discursive maximum. Furthermore, the DEA method application does not give a ready-to-use recipe for improving the efficiency of particular ineffective decision-making units taking into account efficiency differences. The assessment of hospital treatment efficiency in the scope of treating lifestyle diseases used the BCC method (Banker, Charnes, Cooper, 1984) with varying returns to scale

Assumptions of DEA Method
The DEA method is applied to estimate the operation efficiency of various entities called Decision-Making Units (DMUs). A DMU's efficiency is measured relative to other DMUs considered efficient in a studied group, hence forming an efficiency frontier. DEA method assumptions are as follows: there are n DMUs, all of which utilise m various inputs to produce s various outputs. Volumes of inputs and outputs are above or equal to zero and at least one input and one output exceed zero for each decision-making unit. The adopted method has many advantages; it, among others, does not require weights to be known; weights that maximise its efficiency are sought for every unit. Variables describing inputs and outputs may have different units of measure and, importantly, the method does not average values but identifies extreme ones. Technical efficiency, i.e. the efficiency of a technology of transforming inputs into outputs, is a quotient of the weighted sum of outputs to the weighted sum of inputs: where: θ -efficiency, Returns to scale inform how much less inputs might be utilised if the volume of outputs was maximal.

Data Used in the Analysis
The

Results of the Analysis
An optimization analysis was carried out using EXCEL. A disadvantage of that optimisation method was the need to repeatedly find solutions for consecutive years from 2003 to 2017.
According to the DEA method requirements, it was assumed that provinces were homogenous and operated following the same principles in the same economic conditions. Partial results of determined indicesλ j for provinces are presented in (Table 1)   As a result, a system of basic hospital provision of healthcare services (SPSZ) was introduced as part of the so-called Polish hospital network. Pursuant to the new Act, NHF provincial branches will publish (every 4 years) in the Public Information Bulletin lists of service providers qualified to individual levels of the security system with an indication of all profiles of the security system and the ranges or additional types under which they will provide healthcare services in the security system.   (Table 3).
In Poland, there are more and more healthcare entities (including hospitals) in which optimization measures are implemented and their economic results show that it is possible to simultaneously fulfill the mission towards patients and maintain profitability. Effective management and understanding of economic processes affects the right decision making that brings the expected results. This is confirmed by the fact of technical efficiency in the treatment of lifestyle diseases in provinces.
x -inputs should be reduced; * -inputs used at 99%.  (Table 4). of the analysed specialities compared to the Śląskie province. Based on the above, it can be concluded that there was a significant improvement in efficiency related to the use of inputs in hospital care over the fifteen years.

Conclusions
Inter-province diversities in Poland arise from diversities in processes that take place in specific areas of Poland and translate into the constant lack of cohesion, despite expected uniformity, especially in the healthcare sector. Healthcare efficiency is multidimensional (it can be evaluated applying numerous measures concerning such areas as: resources, costs, productivity and quality), hence becoming difficult to analyse and assess. The received results of assessing the efficiency of hospital care in the treatment of lifestyle diseases from the spatio-temporal point of view may serve as a basis of decisions on regional healthcare policy creation.
The society is ageing and we are affected by the lifestyle diseases of the 21st century that require expensive treatment, hence justifying further analyses of the efficient use of financial and human resources.
This study focuses exclusively on the overall assessment of effectiveness in the treatment of lifestyle diseases in provinces. Expanding research in this area will be possible after obtaining more detailed statistical data, or establishing cooperation with the medical community.
Hospital treatment is associated with comprehensive medical care (diagnosis, treatment, care, rehabilitation). Hospital treatment takes place in the form of: hospitalization (admission can be immediate if your health condition requires it), planned hospitalization (the date of admission to the hospital is determined in advance) and treatment one day. Providing healthcare services under the so-called "One-day treatment" did not significantly reduce queues. Hospitals provide 24-hour medical, nursing or obstetric care on all days of the week (except for service providers who only offer one day treatment), which is very expensive.
The prolonged stay of the patient in the hospital (this applies especially to the elderly, who there is no one to pick up or do not want to pick up from the hospital) than the required provision of a medical service, this leads to increased costs and therefore less efficiency, despite the greater use of bed resources. The problem of ordering resources in healthcare has not yet been solved.
Confirmation of the need for further and more detailed research using a technical efficiency analysis in the field of medical activity in provinces is the statement of a doctor, currently a politician and a local government representative (Menedżer Zdrowia, Issues 1-2/2020). Healthcare experts point to the problems arising with the valuation of services by the National Health Fund, which have led to significant differences in the profitability of medical activities. This forced managers of many institutions to prefer more profitable services. In many cases, this has nothing to do with patients' actual needs and health priorities. There are still difficulties with access to medical services, and this translates into an increase in the role of the commercial services sector and the wage expectations of staff employed in the insurance sector. Specialist doctors are increasingly providing advice outside the insurance system, where administrative requirements are much smaller.
Improving the availability of medical services for patients requires a rapid increase in health care expenditure and changes in the algorithm for allocating funds between provinces, as the diagnosed differences between regions are already too large. Then it will be possible to increase expenditure in provinces less rich in funds from the National Health Fund, without worsening the situation in regions with better access to medical services.