A healthy lifestyle: The product of opportunities and preferences

In this explorative study we examine factors explaining individual choice of lifestyle. The empirical analysis of smoking, exercising and diet show that the mechanisms determining people’s lifestyle are complex. We argue that the economic models on the demand for health is a meaningful framework for analysing this issue, but that it needs some refinements. A suggestion for further analytical work is therefore to reformulate the model to incorporate own past behaviour (habits), the society individuals belongs to (traditions and norms), as well as a more immediate effect on utility of lifestyle.Health demand models; lifestyle; ordered probit analysis

General Practice: Four Empirical Essays on GP Behaviour and Individuals’ Preferences for GPs

On June 1, 2001 a reform took place in Norwegian general practice. This implied some advantages of importance to empirical analysis. First, a new organisation and a new payment system were introduced, which makes it possible to perform before-after analysis. Second, the GPs' preferred list-sizes are known, which makes it possible to analyse the effect of patient constraints for individual GPs. Third, the size and composition of patient-lists are known on the individual practice level. Previously, it was not known whether consultations provided during a certain period were given to a large or a small number of persons, and this made it difficult to compare practice styles. If, for instance, two GPs provide the same number of services during one year, but GP A is responsible for twice as many patients as GP B, GP B has a more service-intensive practice style. When information on the number of patients on the list is not known, we might erroneously conclude that A and B have the same practice style. Last, but not least, the population filled in an entry form ahead of the nationwide reform - which gives us information on preferences for GPs for the whole population. Report 2004: 1 "General Practice: Four Empirical Essays on GP Behaviour and Individuals Preferences for GPs" focuses on the General Practitioner reform. Four essays show different impacts this reform had on the general practitioners practice and preferences in the population. Summing up the reform in general practice is very well suited for collecting interesting data and doing empirical analysis. The first three analyses in this doctoral thesis by Hilde Lurås are based on the evaluation of the list patient trial (in four municipalities in 1993-1996). The last analysis is based on the evaluation of the nationwide reform in 2001.General practice; Payment systems; Capitation; Service provision; Preferences; Applied econometrics

Individuals' preferences for GPs Choice analysis from the establishment of a list patient system in Norway

The purpose of this paper is to gain more knowledge concerning individuals’ preferences for alternative GPs within a municipality. We have data on the population’s first, second and third choice of GPs. The data stem from the entry form the inhabitant filled in as a result of the implementation of a list patient system in general practice in Norway. To assess the potential demand for GPs3 or individuals’ request for a position on a certain GP’s list, we formulate and estimate a structural demand model based on probabilistic theories of individual choice behaviour. The model originates from the work of Luce (see for instance Luce, 1959 and Block and Marschak, 1960). Such models are successfully used to obtain knowledge of people’s preferences for different transportation vehicles. We raise the question of whether individuals’ choice of GPs is informed or purely random, as well as the question of whether observable demographic characteristics of a GP can tell us anything about the person who wants him or her as a personal physician. We find systematic dependencies between characteristics of an individual and characteristics of his or her choice of a GP. But we also find that the random part plays a major role in the choice process. In the last part of the paper we discuss policy implications of our findings. Central points are both how local health authorities can use the information on rankings to put together collegiums of GPs that serve the need – or the demand – of the inhabitants in the best way, and how a payment system for GPs should be designed if our results should be taken into account.General practitioner; GP; individual preferences

The interaction between patient shortage and patients waiting time

We study the interaction between patient shortage and patients' waiting time to get an appointment. From a theoretical model we predict that physicians experiencing a shortage of patients offer their patients a shorter waiting time than their unconstrained colleagues. This happens because a shorter waiting time is expected to lower the threshold for seeking care, and hence, to increase the number of patient-initiated contacts. But it also happens because a shorter waiting time can be a mean to attract new patients. The hypotheses are supported by some preliminary results from a sample of Norwegian general practitioners participating in a capitation trial.General practitioner; patient shortage; waiting time

The importance of micro-data for revaealing income motivated behaviour among GPs

The objective of this paper is to demonstrate that micro data is fundamental for the study of income motivated behaviour among general practitioners (GPs). We argue that a GP who experiences a shortage of patients in a mixed capitation and fee for service payment system, is likely to have a more service intensive practice style than his unconstrained colleagues. If he cannot have his optimal number of patients, a second best is to increase the number of services per patient if the income per time unit of providing services is greater than the marginal valuation of leisure. An empirical test requires micro data of GPs' rationing status. Data from the Norwegian capitation experiment provide us with this opportunity. We find that the effect of patient shortage (strong rationing) on a GP's income from fees per patient is positive and statistically significant. Furthermore, we find that only the municipality with the lowest GP density has a negative and statistically significant effect. If only GP density data would have been available, we might erroneously have concluded that service provision among GPs is not income motivated. The reason is that aggregate data miss the within municipality variation in the actual number of patients relative to GPs' preferred numbers. We conclude that macro data of GP density in an area are not likely to be useful in this context because the effect of better access is often not distinguishable from the effect of physician initiated services.General practitioners; income motivated behaviour; patient shortage; service intensive; Norwegian capitation experiment

Patient switching in a list patient system

We study whether the information patients have about physician quality when they choose a physician, influences their probability of switching physicians. We also study whether a physician with unfavorable characteristics, as perceived by patients (ex post), can compensate for patient switching by providing a higher quantity of services to his patients. If so, a trade-off exists between quality characteristics and quantity of services in the physician services market. From panel data covering the entire population of Norwegian general practitioners, we find that information on physician quality, as perceived by patients, has a huge effect on the volume of patients switching physicians. We also find that although physicians who experience patient shortages in general provide more services to their patients than physicians who have enough patients, the increased level of service provision only has a very small impact on the number of patients who decide to switch. We conclude that a higher level of service provision does not seem to compensate for negative characteristics (patients’ impression of competence, empathy etc) of less popular physicians. We suggest that information about the volume of patient switching at the physician practice level should be made public.Switching; Economic motives; Capitation; General practice; Patient shortage

I skyggen av Fastlegeordningen: Hvordan har det gått med det offentlige legearbeidet?

Kommunene har ansvar for å skaffe leger som kan utføre arbeid ved sykehjem, helsestasjon og skolehelsetjeneste, samt samfunnsmedisinske oppgaver som planlegging og beredskapsarbeid i forbindelse med ulykkeshåndtering, miljørettet helsevern, smittevern og administrative oppgaver. Det offentlige legearbeidet er et viktig tilbud til innbyggerne i en kommune. Det har tidligere vært vanskelig å få privatpraktiserende leger til å utføre denne typen arbeid fordi det har blitt regnet som dårlig betalt i forhold til privatpraktiserende praksis. Leger som er fast ansatt i kommunene har derimot generelt vært mer positive til å påta seg offentlig legearbeid. Med innføringen av fastlegeordningen (FLO) i 2001 ble det åpnet for at kommunene kunne pålegge fastlegene offentlig legearbeid inntil 7,5 timer per uke. En ny rapport fra Institutt for helseledelse og helseøkonomi, viser at det er stor variasjon i hvor mye fastlegene deltar i dette arbeidet etter reformen. Totalt er det kun 17,3 % av fastlegene som arbeider mer enn 7,5 timer i uka for kommunen. I 2002 arbeidet fastlegene i gjennomsnitt 5,55 timer per uke med offentlig legearbeid. Det virker som kommunene ikke utnytter potensialet påleggsklausulen gir for å få leger til å arbeide med oppgaver i det offentlige, sier Hilde Lurås en av forskerne bak rapporten. Dersom alle fastlegene i utvalget som i dag jobber mindre enn 7,5 timer, arbeidet 7,5 timer per uke, kunne det samlede offentlige legearbeidet økes med 40 %. Spørsmålet er imidlertid om det er ønskelig at det offentlige legearbeidet skal organiseres ved at alle fastleger pålegges å delta eller om det kan tenkes andre ordninger.FLO; fastlegeordningen; offentlig legearbeid; sykehjem

Strategier for bedre helse og funksjonsevne blant eldre

Fram mot 2050 blir det flere eldre, og en høyere andel eldre i befolkningen enn det som er tilfelle i dag. Ifølge befolkningsframskrivinger vil antall personer over 67 år fordobles de nærmeste 50 år og for aldersgruppen over 90 år blir veksten enda sterkere. Siden utgiftene til helse- og omsorgstjenester er høyere blant eldre enn i befolkningen for øvrig, er det økte tjenestebehovet dette medfører en stor politisk utfordring, finansielt og realøkonomisk. I forbindelse med Stortingsmeldingen om framtidas pleie- og omsorgstjeneste som skal legges fram høsten 2005 har vi på oppdrag fra Helse- og omsorgsdepartementet (HOD), sett nærmere på forebyggingstiltak som kan bidra til bedre helse og funksjonsevne blant eldre. Vi har av hensyn til omfanget av rapporten i hovedsak vektlagt helsetjenestetiltak. Betydningen av en aldrende befolkning for det framtidige behovet for helse- og omsorgstjenester diskuteres i avsnitt 2, og som gjennomgangen viser er det i litteraturen en viss uenighet knyttet til i hvilken grad utgiftene til helse- og omsorgstjenester øker som følge av at befolkningen eldes. Mennesker eldes forskjellig, og det er store individuelle forskjeller når det gjelder samlet hjelpebehov over livsløpet. Avsnitt 3 tar for seg helse, funksjonssvikt og sykdom i alderdommen, og hva som kjennetegner eldre med god funksjonsevne. Vi omtaler også de vanligste årsaker til helseproblemer og nedsatt funksjonsevne hos eldre.aldrende befolkning; førebygging; helse og omsorgstjenester

Does monetary punishment crowd out pro-social motivation? The case of hospital bed-blocking

We study whether the use of explicit monetary incentives might be counter-productive. In particular, we focus on the effect of fining owners of long-term care institutions who prolong length of stay at hospitals. We outline a simple theoretical model, based on motivational crowding theory, deriving the conditions for explicit monetary incentives to have potentially counterproductive effects. In the empirical part, we exploit a natural experiment involving changes in the catchments areas of two large Norwegian hospitals. We find that bed-blocking is reduced when transferring long-term care providers from a hospital using monetary fines to prevent bed-blocking to a hospital not relying on this incentive scheme, and vice versa. We interpret these results as examples of monetary incentives crowding out agents’ intrinsic motivation, leading to a reduction in effort.Motivation crowding; Intrinsic motivation; Monetary punishment; Hospital bed blocking

Utviklingen i fastlegenes listelengder, driftsinntekter og takstbruk

Fastlegene i de tidligere forsøkskommunene har i 2003 kortere lister enn de hadde da fastlegeforsøket ble igangsatt i 1993. Listene er imidlertid fremdeles lengre i disse kommunene enn i landet for øvrig. Samtidig ser vi at gjennomsnittslegen i forsøkskommunene har færre ledige plasser på sin liste enn fastlegene ellers i landet. Dette henger trolig sammen med at det i de tidligere forsøkskommunene fortsatt er en dårligere legedekning enn landsgjennomsnittet for norske kommuner. I perioden etter reformen har gjennomsnittslegen i forsøkskommunene nedjustert sine listetak. På landsbasis har omtrent 21 % av fastlegene oppjustert sitt listetak fra 2001 til 2003, mens 22 % har nedjustert sine listetak. Siden den landsomfattende ordningen ble innført har utviklingen gradvis gått i retning av at færre fastleger opplever å ha kortere liste enn det oppgitte listetaket. I perioden 1994 til 2003 har brutto driftsinntekter for fastlegene i de tidligere forsøkskommunene økt. Veksten i driftsinntekter per person har vært høyere enn veksten i total driftsinntekt. Før den landomfattende reformen hadde legene i forsøkskommunene betydelig høyere driftsinntekter enn i landet for øvrig, noe som trolig kan forklares med den lave legedekningen i disse kommunene. Fastlegene i forsøkskommunene har fortsatt noe høyere driftsinntekter enn ellers i landet, men forskjellene har blitt mindre i perioden etter 2001. Bruken av ordinær konsultasjonstakst, bruken av enkel pasientkontakt og samlet bruk av laboratorietakster per person på fastlegens liste har gått ned i perioden 2001-2003. Bruken av tidstaksten er imidlertid på et litt høyere nivå i 2003 enn i 2001. Det kan altså tyde på at befolkningen får noen færre konsultasjoner, men at konsultasjonene i gjennomsnitt har blitt lengre. Resultatene tyder også på at spesialister i allmennmedisin har en noe annen takstbruk enn ikke-spesialister, samt at leger med kortere listelengde enn oppgitt listetak, yter flere og lengre konsultasjoner per pasient på lista en de øvrige fastlegene.fastlegeordningen; listelengde; fastelegereformen