Skill Formation among Vocational Rehabilitation Clients – Public Policy vs Private Incentives

In this paper we analyse individual vocational rehabilitation clients’ decisions to enter active training or not. Although the Government pays the direct costs of training, the composition of the total costs of training may be decisive for individual choices. Based on labour market theory, we relate background characteristics of the clients to monetary opportunity costs and non-monetary costs of training, arguing that training choices are a consequence of differences in costs of training. We use a ten percent sample of participants in educational programs, work related training and non-participants who entered the Norwegian vocational rehabilitation sector in the period from 1989 to 1993, a total of 6653 persons. We find that the background characteristics of persons investing in educational training differ along several dimensions compared both to persons attending work related training and to clients not participating in training at all.Public policy; private incentives; costs of training; educational training; work related training; vocational rehabilitation

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.

Reablement in community-dwelling older adults: a cost-effectiveness analysis alongside a randomized controlled trial

Background: In the face of a growing number of older adults in the population, policy-makers in high-income countries are seeking new ways to reduce the expected growth in long-term care expenditure. Research shows that disability is an important determinant of long-term care utilization. In this context, reablement has received increased attention. Reablement is a form of home-based rehabilitation, which focuses on improving independent functioning in daily activities perceived as important by the older adult. Objective: To evaluate the cost-effectiveness of reablement. Methods: The economic evaluation is based on data from a randomized controlled trial in which all participants were assessed at baseline and after 3 and 9 months. The intervention group participated in reablement, while the control group received usual care. The Canadian Occupational Performance Measure (COPM) was used to measure self-perceived activity performance and satisfaction with performance. Cost data were based on daily registrations of usage of home-based care personnel during a period of 9 months. Results: Reablement was found to be more cost-effective than usual care. The assessments of performance and satisfaction regarding daily activities were significantly higher in the reablement group compared with the control group and this was achieved at lower cost. Importantly too, in the post-trial period, the intervention group requested significantly fewer home visits which were, on average, of significantly shorter duration compared with the control group. Expenditure on home visits was significantly lower for the reablement group. Conclusions: Reablement is a more cost-effective intervention compared with usual care. Reablement has a potentially large effect on the demand for compensating home-based care services. Policy-makers should therefore consider implementing reablement on a larger scale

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

Evaluering av tilskuddsordning for helse- og rehabiliteringstjenester : delrapport 3

Hensikten med tilskuddsordningen for helse- og rehabiliteringstjenester (Raskere tilbake), er å bidra til at personer som mottar sykepenger, skal komme raskere tilbake i arbeid enn de ellers ville gjort. Tilskuddsordningen ble innført i 2007, og i denne rapporten redegjøres det for resultatene fra evalueringen av ordningen. Evalueringen er kun basert på aktivitetstall for 2008. I 2008 var det 22909 personer som mottok behandling gjennom Raskere tilbake tiltak i regi av spesialisthelsetjenesten, og 4060 personer deltok på tiltak i regi av NAV. Det ble samlet brukt 758 millioner kroner på Raskere tilbake i 2008. Vi finner signifikante tiltakseffekter for kirurgisk og medisinsk behandling analysert samlet. De som har deltatt på Raskere tilbake tiltak har i gjennomsnitt 4,3 dager kortere sykepengeperioder sammenliknet med personer som mottar slik behandling gjennom det ordinære behandlingstilbudet ved sykehusene. Effekten er særlig sterk for kirurgi når gruppene av pasienter analyseres hver for seg. Mens medisinske pasienter som har deltatt på Raskere tilbake ikke har signifikant kortere sykefravær enn sammenlikningsgruppen, så reduseres sykefraværet med rundt 14 dager for kirurgiske Raskere tilbake pasienter sammenliknet med de som mottar kirurgisk behandling gjennom det ordinære tilbudet. Drivkraften bak resultatene er imidlertid ikke at behandlingen i seg selv reduserer sykefraværet, men at Raskere tilbake bidrar til å redusere ventetidene på behandlingen. Vi ser med andre ord en klar kapasitetseffekt, i tråd med det Sykefraværsutvalget forventet av satsingen. Ventetidene reduseres med rundt 18 dager når vi ser medisinsk og kirurgisk behandling under ett. Det er altså ingen dag-for-dag sammenheng mellom reduserte ventetider og reduksjon i sykefraværet. Vi mener at det også er rimelig å hevde en sykefraværsreduserende effekt for de som mottok kirurgisk behandling hos private leverandører, mens vi ikke kan konkludere det samme for tilbudet innen psykiatri og arbeidsrettet rehabilitering i regi av de regionale helseforetakene. I sistnevnte analyser er imidlertid utvalget lite og analyseresultatene usikre. Når det gjelder NAV- tiltakene, så har vi ikke kunnet gjennomføre tilfredsstillende analyser med det foreliggende datamaterialet. Det synes som om vi ikke har maktet å kontrollere for at tiltaksgruppen skiller seg vesentlig fra kontrollgruppen. Dette betyr at man må være åpen for at midlene som NAV disponerer kan ha hatt en sykefraværsreduserende effekt for de som har deltatt. Våre beregninger tyder på at Raskere tilbake samlet sett trolig ikke er en suksess i samfunnsøkonomisk forstand, fordi reduksjonen i sykefraværet er for liten. Ordningen er imidlertid meget kompleks og består av mange ulike typer tilbud. Dette, sammen med den nevnte usikkerheten knyttet til analyseresultater, tilsier at en må være åpen for at deler av ordningen kan ha samfunnsøkonomiske gunstige effekter. Ordningen har uansett bidratt til at grupper av sykmeldte har kommet betydelig raskere til behandling, dvs. at ventetiden har blitt redusert sammenliknet med de som venter på ordinær behandling. Dette har skjedd uten at ventetidene har gått opp for sistnevnte grupper av pasienter

Worker and workplace determinants of employment exit: A register study

Background Workers with chronic illness are in higher risk of unemployment. This article investigated the worker and workplace characteristics associated with labour market inclusion for workers with a diagnosed chronic illness. Methods Linked employer-employee register data covering all Norwegian employers and employees each month from February 2015 to December 2019 were merged with patient data from specialist healthcare (136 196 observations (job spells); 70 923 individual workers). Survival analysis was used to estimate the risk of employment exit, with age, gender, chronic illness, full-time/part-time employment, skill level, marital status, children in household, branch, share of chronically ill workers, firm size and unemployment rate as covariates. Results 85% of the study population was employed in December 2019; 58% remain employed throughout the follow-up period. Mental illness, male gender, young age, part-time employment and lower skill levels were the worker-level predictors of labour market exit. Employments in secondary industries, in firms with high shares of chronically ill workers and, to some extent, in larger firms were the significant workplace-level determinants. Conclusion Only a minority of our sample of workers with chronic illness experienced labour market exclusion. Targeted measures should be considered towards workers with poor mental health and/or low formal skills. Chronically ill workers within public administration have the best labour market prospects, while workplaces within the education branch have an unfulfilled potential.publishedVersio

Does monetary punishment crowd out pro-social motivation? A natural experiment on hospital length of stay

We study whether the use of monetary incentives might be counter-productive. In particular, we analyse the effect of fining owners of long-term care institutions who prolong length of stay at hospitals. Exploiting a unique natural experiment involving changes in the catchment areas of two large Norwegian hospitals, we find that hospital length of stay are longer in the hospital using fines to reduce length of stay compared with the hospital not using monetary punishment. We interpret these results as examples of monetary incentives crowding-out agents’ intrinsic motivation, leading to a reduction in effort.Fundação para a Ciência e a Tecnologia (FCT

Acute management of fractures in primary care - a cost minimisation analysis

Background In Norway, primary healthcare has first-line responsibility for all medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care in hospitals. However, the cooperating municipalities of Bykle and Valle have X-ray facilities and handle minor fractures locally. The aim of this study was to estimate the costs of X-ray diagnosis and initial treatment of fractures at the local primary care centre compared with initial transport and treatment in hospital. Methods We conducted a cost minimisation analysis by comparing expected costs of initial examination with X-ray and treatment of patients with fractures or suspected fractures at two possible sites, in the local municipality or at the hospital. A cost minimisation analysis is an economic evaluation based on the assumption that the outcomes of the two treatment procedure regimens are equal. Costs were estimated in Euros (EUR) using 2021 mean exchange rates. Results In 2019, we identified a total of 403 patients with suspected fractures in the two municipalities. Among these, 12 patients bypassed the primary care system as they needed urgent hospital care. A total of 391 injured patients were assessed with X-ray at the primary health care centres, 382 received their initial treatment there, and nine were referred to hospital. In an alternative hospital model, without X-ray and treatment possibilities in the municipality, the 382 patients would have been sent directly to hospital for radiological imaging and treatment. The total cost was estimated at EUR 367,756 in the hospital model and at EUR 69,835 in the primary care model, a cost saving of EUR 297,921. Conclusion Based on cost minimisation analysis, this study found that radiological diagnosis of suspected fractures and initial treatment of uncomplicated fractures in primary care cost substantially less than transport to and treatment in hospital.publishedVersio

BPA-ordningen: en analyse av klager til Statsforvalteren før og etter rettighetsfesting

I denne artikkelen studerer vi klager på brukerstyrt personlig assistanse (BPA) før og etter rettighetsfestingen i 2015. BPA er en relativt ny velferdstjeneste, og tjenestens utforming og kriterier for tildeling har vært gjenstand for regelmessig debatt. Klagemuligheter er et viktig (juridisk) element når tjenester rettighetsfestes, og klager på BPA er lite studert. Basert på klagestatistikk for årene 2012–2020 undersøker vi om antall BPA-klager til Statsforvalteren på kommunale vedtak endret seg etter rettighetsfesting, og om utfallene av disse klagene endret seg sammenliknet med førsituasjonen. Ved hjelp av kvalitative data undersøker vi hvorvidt dette reflekterer ulike praksiser mellom statsforvalterembetene. Vi finner statistisk signifikante endringer etter rettighetsfestingen: Klagesannsynligheten har økt, mens sannsynligheten for at Statsforvalteren stadfester kommunens vurdering, er redusert. Vi finner også at klagesaksbehandlingen fremdeles varierer mellom statsforvalterembetene, noe som bekreftes gjennom intervjuer med representanter for Statsforvalteren.publishedVersio

User perspectives on the role of local services in promoting labor market participation of people with chronic illnesses

How do local Norwegian work, welfare, and health services (WWH services) support the labor market integration of chronically ill people? We discuss how user organization representatives evaluate the role of municipal-level service support in facilitating labor market participation of people with chronic illnesses and disabilities, and to what extent the views of user organizations are requested and included in local service development. We thus contribute to the limited research on the role of WWH services for work inclusion from the user perspective. Our analysis rests on an original web-based survey, combining qualitative and quantitative data, and a focus group discussion. Although user representatives call for strengthening of services, they also view employers’ adaptations as being more important than local services. And despite their expertise, user organizations are only included in local service development to a limited extent.publishedVersio