The effect of patient shortage on general practitioners’ future income and list of patients

The literature on supplier inducement suffers from inability to distinguish the effect of better access from the effect of patient shortage. Data from the Norwegian capitation trial in general practice give us an opportunity to make this distinction and hence, study whether service provision by physicians is income motivated. In the capitation trial each general practitioner (GP) has a personal list of patients. The payment system is a mix of a capitation fee and a fee for service. The data set has information on patient shortage, i.e. a positive difference between a GP’s preferred and actual list size, at the individual practice level. From a model of a GP’s optimal choice we derive the optimal practice profile contingent on whether a GP experiences a shortage of patients or not. To what extent GPs, who experience a shortage, will undertake measures to attract patients or embark on a service intensive practice style, depends on the costs of the various measures relative to their expected benefit. The model classifies GPs into five types. In the empirical analysis a panel of GPs is followed for five years. Hence, short-term effects due to transition to a new system should have been overcome. We show that even in the longer run, GPs who experience a shortage of patients have a higher income per listed person than their unrationed colleagues. This result is robust with regard to correction for potential selection bias based on observable and unobservable characteristics. We do not find any significant difference in income per listed person dependent on whether a rationed GP obtains an increase in the number of patients or not. A policy implication is that patient shortage is costly to the insurer because of income motivated behavior of unknown benefit to the patient.Economic motives; Capitation; General practice; Patient shortage; Service provision

A study of income-motivated behavior among general practitioners in the Norwegian list patient system

In the Norwegian capitation system each general practitioner (GP) has a personal list of patients. The payment system is a mix of a capitation fee and fee-for-service. From a model of a GP’s decisions we derive the optimal practice profile contingent on whether a GP experiences a shortage of patients or not. We also find the conditions for whether a GP, who experiences a shortage of patients, is likely to increase the number of services he provides to his patients. Data give us the opportunity to reveal patient shortage, i.e. a positive difference between a GP’s preferred and actual list size, at the individual practice level. From the analysis of 2587 Norwegian GPs (out of a total 3650) the main result is that patient shortage has a positive effect on a GP’s intensity of service provision and hence, on the income per listed person. We also find that a GP’s income per listed person is influenced by the composition of the list according to indicators of need for services, and of accessibility according to the GP density in the municipality. These results are also valid when possible selection bias is accounted for, although the magnitude of the effects is then smaller.economic motives; capitation; general practice; patient shortage; service provision

An exploratory study of associations between social capital and selfassessed health in Norway

The objective of this study is to estimate associations between social capital and health when other factors are controlled for. Data from the survey of level-of-living conditions by Statistics Norway are merged with data from several other sources. The merged files combine data at the individual level with data that describe indicators of community-level social capital related to each person’s county of residence. Both cross-sectional and panel data are used. We find that one indicator of community-level social capital — voting participation in local elections — was positively associated with self-assessed health in the cross-sectional study and in the panel data study. While we find that religious activity at the community-level has a positive effect in the cross-sectional survey and a non-significant effect in the panel survey, we find that sports organizations have a negative effect on health in the cross-sectional survey and a non-significant effect in the panel study. This result indicates that sports organizations represent bonding social capital.social capital; health; Norway

Genetic Testing When There is a Mix of Compulsory and Voluntary Health Insurance

Genetic insurance can deal with the negative effects of genetic testing on insurance coverage and income distribution when the insurer has access to information about test status. Hence, efficient testing is promoted. When information about prevention and test status is private, two types of social inefficiencies may occur; genetic testing may not be done when it is socially efficient and genetic testing may be done although it is socially inefficient. The first type of inefficiency is shown to be likely for consumers with compulsory insurance only, while the second type of inefficiency is more likely for those who have supplemented the compulsory insurance with substantial voluntary insurance. This second type of inefficiency is more important the less effective prevention is. It is therefore a puzzle that many countries have imposed strict regulation on the genetic information insurers have access to. A reason may be that genetic insurance is not yet a political issue, and the advantage of shared genetic information is therefore not transparent.Genetic testing insurance, private information, compulsory/voluntary mix

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

Market Conditions and General Practitioners’ Referrals

We study how market conditions influence referrals of patients by general practitioners (GPs). We set up a model of GP referral for the Norwegian health care system, where a GP receives capitation payment based on the number of patients in his practice, as well as fee-for-service reimbursements. A GP may accept new patients or close the practice to new patients. We model GPs as partially altruistic, and compete for patients. We show that a GP operating in a more competitive market refers more. To retain patients in his practice, a GP satisfies patients’ requests for referrals. Furthermore, a GP who faces patient shortage will refer more often than a GP who has enough patients. More referrals may add to profits from future treatments. Using data of radiology referrals by GPs in Norway, we test and confirm our theory.Physician; service motive; profit motive; referral; radiology

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

Impact of the public/private mix of health insurance on genetic testing

Privacy of information is a central concern in the debate about genetic testing. Two types of social inefficiencies may occur when information about prevention and test status is private; genetic testing may not be done when it is socially efficient and genetic testing may be done although it is socially inefficient. The first type of inefficiency is shown to be likely for consumers with public insurance only, while the second type of inefficiency is likely for those with a mix of public/private insurance. This second type of inefficiency is shown to be more important the less effective prevention is.Health insurance; genetic testing

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

Regulation versus practice - The impact of accessibility on the use of specialist health care in Norway

In Norway specialized health services are provided both by public hospitals and by privately practicing specialists who have a contract with the public sector. Patients’ co-payment is the same irrespective of the type of provider they visit. The ambition of equity in the allocation of medical care is high among all political parties. The instruments for auditing whether these goals are fulfilled are not equally ambitious. The objective of the present study is to explore whether laws and regulations that govern the allocation of specialist health care resources in fact are fulfilled. Panel data from the Survey of Living Conditions are merged with data on capacity and spatial access to primary and specialist care. We find that accessibility and socio-economic variables play a considerable role in determining both the probability of at least one visit and the number of visits to a private specialist. A person with a higher university degree living in a municipality with the highest value of the geographical accessibility index has a 46%-points higher probability of at least one visit to a private specialist compared with a person with junior high living in a municipality with the lowest value of the accessibility index. With regard to visits to a hospital outpatient department these variables are not found to have significant effects. We conclude that public ambitions and regulations are fulfilled for specialist services provided by public hospitals. With regard to the provision of services provided by publicly financed private specialists we find a discrepancy between public goals and surveyed practice.specialist health services; utilization; equity; private/public provision; survey data