Inequity in the use of physician services in Norway. Changing patterns over time

We analyze and compare inequity in use of physician visits (GP and specialists) in Norway based on data from the Surveys of Living Conditions for the years 2000, 2002 and 2005. Within this period the Norwegian public health care system underwent two major reforms, both aimed at ensuring equitable access to health care services for the entire population. A list patient system was introduced in the primary health care sector in 2001, and in 2002 the ownership of hospitals was moved from the regional to the state level. At both care levels a real increase in public expenditures followed in the wake of the reforms. We apply the indirect standardization approach and estimate the relationship between health care use, need and other control variables by linear and nonlinear regression. We measure horizontal inequity in physician visits by concentration indices and investigate changes in inequity over time when decomposing the concentration indices into the contribution of its determinants. For specialist services we find pro-rich inequity in the probability of seeing an outpatient specialist in all three years. Estimated concentration indices are reduced in magnitude over time and no longer statistically significant in 2005. Inclusion of more information about need for medical care in 2002 and 2005, results in larger and statistical significant concentration indices. In sum, in a period with important changes in the health care system aimed at obtaining equity, inequity in medical specialist utilization has been reduced but not removed in Norway. §Analysis of Health Care Markets; Government Policy; Regulation; Public Health

Education and Fertility: Evidence from a Natural Experiment

In many developed countries a decline in fertility has occurred. This development has been attributed to greater education of women. However, establishing a causal link is difficult as both fertility and education have changed secularly. The contribution of this paper is to study the connection between fertility and education over a woman’s fertile period focusing on whether the relationship is causal. We study fertility in Norway and use an educational reform as an instrument to correct for selection into education. Our results indicate that increasing education leads to postponement of first births away from teenage motherhood towards having the first birth in their twenties and, for a smaller group, up to the age of 35-40. We do not find, however, evidence that total fertility falls as a result of greater education.Analysis of Education; Fertility; Family Planning; Child Care; Children; Youth; Human Capital; Skills; Occupational Choice; Labor Productivity

Waiting time and socioeconomic status - an individual–level analysis

Waiting time is a rationing mechanism that is used in publicly funded healthcare systems. From an equity viewpoint, it is regarded as preferable to co-payments. However, long waits are an indication of poor quality of service. To our knowledge, this analysis is the first to benefit from individual-level data from administrative registers to investigate the distribution of waiting time with respect to socioeconomic status. Furthermore, it makes use of an extensive set of medical information that serves as indicators of patient need. Differences in waiting time by socioeconomic status are detected. For men there is a statistically highly significant negative association between income and waiting time. More educated women, i.e., having an education above compulsory schooling, experience lower waiting time than their fellow sisters with the lowest level of education.Health

Inequity in the use of physician services in Norway before and after introducing patient lists in primary care

<p>Abstract</p> <p>Background</p> <p>Inequity in use of physician services has been detected even within health care systems with universal coverage of the population through public insurance schemes. In this study we analyse and compare inequity in use of physician visits (GP and specialists) in Norway based on data from the Surveys of Living Conditions for the years 2000, 2002 and 2005. A patient list system was introduced for GPs in 2001 to improve GP accessibility, strengthen the stability of the patient-doctor relationship and ensure equity in the use of health care services for the entire population.</p> <p>Method</p> <p>We measure horizontal inequity by concentration indices and investigate changes in inequity over time when decomposing the concentration indices into the contribution of its determinants.</p> <p>Results</p> <p>We find that pro-rich inequity in the probability of seeing a private outpatient specialist has declined, but still existed in 2005.</p> <p>Conclusion</p> <p>Improved patient-doctor stability as well as better GP accessibility facilitated by the introduction of patient lists improved access to private specialist services. In particular the less well off benefited from this reform.</p

Continuity of care, measurement and association with hospital admission and mortality: A registry-based longitudinal cohort study

Objective To assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure. Design Registry-based, population-level longitudinal cohort study. Setting Linked data from Norwegian administrative healthcare registries, including 3989 GPs. Participants 757 873 patients aged 60–90 years with ≥2 contacts with a GP during 2016 and 2017. Main outcome measure All-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018. Results We assessed COC using the conventional usual provider of care index (UPCpatient) and an alternative/supplementary index (UPCGP list) based on the COC for all other patients enlisted with the same preferred GP. For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPCGP list shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPCpatient and UPCGP list, respectively. Using UPCGP list, we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education. Conclusions A continuity measure based on each patient’s contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health.publishedVersio

Socioeconomic status and physicians' treatment decisions

This paper aims at shedding light on the social gradient by studying the relationship between socioeconomic status (SES) and provision of health care. Using administrative data on services provided by General Practitioners (GPs) in Norway over a five year period (2008-12), we analyse the quantity, composition and value of services provided by the GPs according to patients' SES measured by education, income or ethnicity. Our data allow us to control for a wide set of patient and GP characteristics. To account for (unobserved) heterogeneity, we limit the sample to patients with a specific disease, diabetes type 2, and estimate a model with GP fixed effects. Our results show that patients with low SES visit the GPs more often, but the value of services provided per visit is lower. The composition of services varies with SES, where patients with low education and African or Asian ethnicity receive more medical tests but shorter consultations, whereas patients with low income receive both shorter consultations and fewer tests. Thus, our results show that GPs differentiate services according to SES, but give no clear evidence for a social gradient in health care provision.COMPETE, QREN, FEDER, FC

Competition and physician behaviour: Does the competitive environment affect the propensity to issue sickness certicates?

JEL Classication: I11; I18; L13Competition among physicians is widespread, but compelling empirical evidence on the impact on service provision is limited, mainly due to lack of exogenous variation in the degree of competition. In this paper we exploit that many GPs, in addition to own practice, work in local emergency centres, where the matching of patients to GPs is random. This allows us to observe the same GP in two di⁄erent competitive environments; with competition (own practice) and without competition (emergency centre). Using rich administrative patientlevel data from Norway for 2006-14, which allow us to estimate high-dimensional xed-e⁄ect models to control for time-invariant patient and GP heterogeneity, we nd that GPs with a fee-for-service (xed salary) contract are 11 (8) percentage points more likely to certify sick leave at own practice than at the emergency centre. Thus, competition has a positive impact on GPssick listing that is reinforced by nancial incentives.OMPETE reference nº POCI-01-0145-FEDER-006683(UID/ECO/03182/2013) , with the FCT/MEC’s (Fundação para a Ciência e a Tecnologia, I.P.) financial support through national funding and by the ERDF through the Operational Programm e on "Competitiveness and Internationalization – COMPETE 2020 under the PT2020 Partnership Agreement»info:eu-repo/semantics/publishedVersio

Competition and physician behaviour: Does the competitive environment affect the propensity to issue sickness certificates?

Competition among physicians is widespread, but compelling empirical evidence on its impact on service provision is limited, mainly due to endogeneity issues. In this paper we exploit that many GPs, in addition to own practice, work in local emergency centres, where the matching of patients to GPs is random. The same GP is observed both with competition (own practice) and without (emergency centre). Using high-dimensional fixed-effect models, we find that GPs with a fee-for-service (fixed-salary) contract are 12 (8) percentage points more likely to certify sick leave at own practice than at the emergency centre. Thus, competition has a positive impact on GPs' sicklisting that is strongly reinforced by financial incentives. (C) 2019 Elsevier B.V. All rights reserved.- We thank two anonymous referees, and participants at PEJ 2017 and EARIE 2017, for valuable comments. This research was supported with funding from the Norwegian Research Council project no. 237991 (Brekke, Holmas and Monstad) and Prisreguleringsfondet (Brekke and Straume). Straume also acknowledges funding from COMPETE (ref. no. POCI-01-0145-FEDER-006683), with the FCT/MEC's (Fundacao para a Ciencia e a Tecnologia, I.P.) financial support through national funding and by the ERDF through the Operational Programme on Competitiveness and Internationalization - COMPETE 2020 under the PT2020 Partnership Agreement

Socioeconomic Status and Physicians’ Treatment Decisions

This paper aims at shedding light on the social gradient by studying the relationship between socioeconomic status (SES) and provision of health care. Using administrative data on services provided by General Practitioners (GPs) in Norway over a five year period (2008- 12), we analyse the quantity, composition and value of services provided by the GPs according to patients' SES measured by education, income or ethnicity. Our data allow us to control for a wide set of patient and GP characteristics. To account for (unobserved) heterogeneity, we limit the sample to patients with a specific disease, diabetes type 2, and estimate a model with GP fixed effects. Our results show that patients with low SES visit the GPs more often, but the value of services provided per visit is lower. The composition of services varies with SES, where patients with low education and African or Asian ethnicity receive more medical tests but shorter consultations, whereas patients with low income receive both shorter consultations and fewer tests. Thus, our results show that GPs differentiate services according to SES, but give no clear evidence for a social gradient in health care provision

Sysselsettingseffekter av pensjonsreformen - avhenger de av helsetilstand.

Denne analysen undersøker om dårlig helse hindrer individer fra å kunne øke sitt arbeidstilbud slik pensjonsreformen la opp til. Vi analyserer effekten av reformen på arbeidsdeltakelse og avtalte timer i arbeid for mennesker med ulik helsetilstand før reformen. Utvalget består av individer som er i arbeid måneden før de fyller 59 år. Våre viktigste funn er at effekten synes å være uavhengig av helsetilstand, og det gjelder for begge kjønn: De med dårligst helse øker arbeidstilbudet minst like mye som de med best helse. Dette gjelder enten vi måler helsetilstand basert på antall fastlegebesøk eller på type helseproblem.publishedVersio