Access to Primary Health Care and Health Outcomes: The Relationships between GP Characteristics and Mortality Rates

This paper analyses the impact of economic conditions and access to primary health care on health outcomes in Norway. Total mortality rates, grouped into four causes of death, were used as proxies for health, and the number of general practitioners (GPs) at the municipality level was used as the proxy for access to primary health care. Dynamic panel data models that allow for time persistence in mortality rates, incorporate municipal fixed effects, and treat both the number and types of GPs in a district as endogenous were estimated using municipality data from 1986 to 2001. We reject the significant relationship between mortality and the number of GPs per capita found in most previous studies. However, there is a significant effect of the composition of GPs, where an increase in the number of fee-for-service GPs reduces mortality rates when compared with GPs employed directly by the municipality.general practitioners (GPs); mortality; morbidity; simultaneity; endogeneity; municipalities; dynamic panel data models

Is There a Demand Response by Patients in Primary Care?

We test whether a demand response by patients exists in the Norwegian primary care sector. In Norway, physicians are remunerated either by salary or by incentive contract, and we have access to a large data survey that allows us to study the relationship between consumer satisfaction with primary physician services and the way physicians are paid. In addition, we can identify areas (municipalities) where market demand for primary physicians’ services is responsive to effort. When a demand response exists, we expect that patients’ benefit is higher and that patients are more satisfied when visiting a contract physician. As expected, we find very small effects of the salary physician density on reported patient satisfaction in municipalities where market demand is nonresponsive to physicians’ choice of effort. In municipalities with responsive market demand, we find a negative association between salary physician density and patients’ satisfaction with their physician.Physician behavior; Remuneration contracts; Patients’ satisfaction

Wages and work conditions as determinants for physicians’ work decisions

It is not uncommon that publicly employed physicians also have income from work outside the hospital, often termed moonlighting. There is little empirical evidence of such activity. In this paper we investigate which factors that may influence physicians’ choice of work between the public hospital sector and elsewhere. An exceptionally high wage increase in 1996 for one group of hospital physicians (assistant physicians) serves as a natural experiment, and we analyse whether wages in general and this reform in particular have affected physicians’ external earnings. For assistant physicians we find that higher wages at public hospitals affect negatively both the decisions to earn income externally, and level of income once active. For consultant physicians, on the other hand, there was no such response to the wage increase. Several hospital specific factors representing job specific work characteristics also matter for physicians’ decisions to moonlight.Physicians; wages; job characteristics; moonlighting; panel data.

A Low-key Social Insurance Reform - Treatment Effects for Back Pain Patients in Norway

This paper estimates treatment effects for back pain patients using observational data from a low-key social insurance reform in Norway. Using a latent variable model we estimate the average treatment effects (ATE), the average effect of treatment on the treated (TT), and the distribution of treatment effects for outpatient treatment at three different locations. To estimate these parameters and the distribution of treatment effects we use a discrete choice model with unobservables generated by a factor structure model. Distance to nearest hospital (in kilometers) is used as an instrument in estimating the different treatment effects. We find a positive effect of treatment of 6 percentage points on the probability of leaving sickness benefits after allowing for selection effects and full heterogeneity in treatment effects. We also find that there are sound arguments for increasing the outpatient program of treating back pain patients.Discrete Regression and Qualitative Choice Models; Discrete Regressors; Proportions; Project Evaluation; Social Discount Rate; General; Unemployment: Models; Duration; Incidence; and Job Search.

A panel data study of physicians’ labor supply: The case of Norway

Physicians are key personnel in a sector which is important due to its size as well as the quality of service it provides. We estimate the labor supply of physicians employed at hospitals in Norway, using personnel register data merged with other public records. A dynamic labor supply equation is estimated using a sample of 1303 physicians observed over the period 1993-97. The methods of estimation are GMM and system GMM. We reject the static model in favor of a dynamic model and obtain a long-run wage elasticity of about 0.55. This is considerably higher than previously estimated for physicians, in particular for those who are not self-employed.Physicians; labor supply; dynamic panel data.

Prioritization and patients' rights: Analysing the effect of a reform in the Norwegian Hospital Sector

The right to equal treatment, irrespective of age, gender, ethnicity, socio-economic status and place of resident, is an important principle for several health care systems. A reform of the Norwegian hospital sector may be used as a relevant experiment for investigating whether centralization of ownership and management structures will lead to more equal prioritization practices over geographical regions. One concern was variation in waiting times across thecountry. The reform was followed up in subsequent years by some other policy initiatives that also aimed at reducing waiting lists. Prioritization practice is measured by a method that takes departure in recommended maximum waiting times from medical guidelines. We merge the information from the guidelines with individual patient data on actual waiting times. This way we can monitor whether each patient in the available register of actual hospital visits has waited shorter or longer than what is considered medically acceptable by the guideline. The results indicate no equalisation between the five new health regions, but we find evidence of more equal prioritization within four of the health regions. Our method of measuring prioritizations allows us to analyse how prioritization practice evolved over time after the reform, thus covering some further initiatives with the same objective. The results indicate that an observed reduction in waiting times after the reform have favoured patients of lower prioritization status, something we interpret as a general worsening of prioritization practices over time.Prioritization; waiting time; hospital reform

A Panel Data Study of Physicians’ Labor Supply: The Case of Norway

Physicians are key personnel in a sector which is important due to its size as well as the quality of service it provides. We estimate the labor supply of physicians employed at hospitals in Norway, using personnel register data merged with other public records. A dynamic labor supply equation is estimated using a sample of 1303 physicians observed over the period 1993-97. The methods of estimation are GMM and system GMM. We reject the static model in favor of a dynamic model and obtain a long-run wage elasticity of about 0.55. This is considerably higher than previously estimated for physicians, in particular for those who are not self-employed.physicians, labor supply, dynamic panel data

Does variation in GP practice matter for the length of sick leave? A multilevel analysis based on Norwegian GP—patient data

In many countries, the social insurance system is under pressure from an ageing population. An increasing number of people are on sickness benefits and disability pensions in Norway. The general practitioner (GP) is responsible for assessing work capacity and issuing certificates for sick leave based on an evaluation of the patient. Although many studies have analysed certified sickness absence and predictive factors, very few studies focus on the length of sick leave and no studies assess its variation between patients, GPs or geographical areas within a multilevel framework. This study aims to analyse factors explaining the variation in the length of certified sick leave and to disentangle patients, GPs and municipality sources of variation in sickness durations for the whole population of Norwegian workers in 2003. This study uses a unique Norwegian administrative data set that merges data from different sources. The study uses amatched patient—GP data set, and employs amultilevel random intercept model to separate out patient, GP and municipality-level explained and unexplained parts of the variation in the certified sickness durations. We find that all observed patient and GP characteristics are significantly associated with the length of sick leaves (LSL). However, 98% of the variation in the LSL is attributed to patient factors rather than influenced by variations in GP practice or differences in municipality-level characteristics. Medical diagnosis is an important observed factor explaining certified sickness durations. Low variations across GPs may imply that the gatekeeping role of Norwegian GPs is weak compared with their advocate role.general practitioners (GPs); length of sick leave; multilevel regression models; matched GP—patient data

Regulation and Pricing of Pharmaceuticals: Reference Pricing or Price Cap Regulation?

We study the relationship between regulatory regimes and pharmaceutical firms’ pricing strategies using a unique policy experiment from Norway, which in 2003 introduced a reference price (RP) system called “index pricing” for a sub-sample of off-patent pharmaceuticals, replacing the existing price cap (PC) regulation. We estimate the effect of the reform using a product level panel dataset, covering the drugs exposed to RP and a large number of drugs still under PC regulation in the time before and after the policy change. Our results show that RP significantly reduced both brand-name and generic prices within the reference group, with the effect being stronger for brand-names. We also identify a negative cross-price effect on therapeutic substitutes not included in the RP-system. In terms of policy implications, the results suggest that RP is more effective than PC regulation in lowering drug prices, while the cross-price effect raises a concern about patent protection.Pharmaceuticals; Price Regulation; Branded-Generic competition.

Margins and Market Shares: Pharmacy Incentives for Generic Substitution.

We study the impact of product margins on pharmacies’ incentive to promote generics instead of brand-names. First, we construct a theoretical model where pharmacies can persuade patients with a brand-name prescription to purchase a generic version instead. We show that pharmacies’substitution incentives are determined by relative margins and relative patient copayments. Second, we exploit a unique product level panel data set, which contains information on sales and prices at both producer and retail level. In the empirical analysis, we find a strong relationship between the margins of brand-names and generics and their market shares. In terms of policy implications, our results suggest that pharmacy incentives are crucial for promoting generic sales.Pharmaceuticals; Pharmacies; Generic Substitution.