Jostein Grytten

Type of contract and supplier-induced demand for primary physicians in Norway

The focus of the present study is to examine whether supplier-induced demand exists for primary care physician services in Norway. We compare how two groups of physicians, with and without incentives to induce, respond to increased competition. Contract physicians receive their income from fee-for-item payments. They have an incentive to compensate for a lack of patients by inducing demand for services. Salaried physicians receive a salary which is independent of output. Even though increased competition for patients reduces the availability of patients, they have no financial incentive to induce. Neither of the two groups of physicians increased their output as a response to an increase in physician density. This result could be expected for salaried physicians, while it provides evidence against the inducement hypothesis for contract physicians.

MORE PHYSICIANS: IMPROVED AVAILABILITY OR INDUCED DEMAND?

A number of empirical studies have shown that there is a negative association between population:physician ratio and utilization of medical services. However, it is not clear whether this relationship reflects supplier-inducement, the effect of lower prices on patient demand, a supply response to variation in health status, or improved availability. In Norway, patient fees and state reimbursement fees are set centrally. Therefore, the correlation between utilization and population:physician ratio either reflects supplier-inducement, a supply response or an availability effect. We applied a theoretical model which distinguished between an inducement and an availability effect. The model was implemented on a cross-sectional data set which contained information about patient visits and laboratory tests for all fee-for-service primary care physicians in Norway. Since population:physician ratio is potentially endogenous, an instrumental variable approach is used. We found no evidence for inducement either for number of visits or for provision of laboratory services.

Consumer satisfaction and supplier induced demand

This study examines the relationship between supply of primary physicians and consumer satisfaction with access to, and quality of, primary physician services in Norway. The purpose is to throw light on a long-standing controversy in the literature on supplier inducement (SID): the interpretation of the positive association between physician density and per capita utilization of health services. We find that an increase in the number of physicians leads to improved consumer satisfaction, and that the relationship between satisfaction and physician density exhibits diminishing returns to scale. Our results suggest that policy-makers can compute the socially optimal density of physicians without knowledge about whether SID exists, if one accepts the (controversial) assumption that consumer satisfaction is a valid proxy for patient utility.

Supplier inducement: Its effect on dental services in Norway

In many western countries, supply of dental services exceeds demand, mainly because of the marked reduction in the prevalence of dental diseases during the last 10-15 years. An important issue is whether dentists can counteract this fall in demand by stimulating increased demand and/or utilization for their services. Some evidence that this may be the case was found in the present study, in Norway. The results indicate that demand and utilization for dental services are influenced by supplier inducement.

A comparison of teeth and implants during maintenance therapy in terms of the number of disease‐free years and costs ‐ an in vivo internal control study

BACKGROUND Little is known about the cost minimization and cost effectiveness involved in maintaining teeth and implants for patients treated for periodontal disease. MATERIALS & METHODS A retrospective study was carried out encompassing all patients who had initial periodontal treatment followed by implant placement and maintenance therapy in a specialist practice in Norway. The neighbouring tooth and the contra-lateral tooth were used as controls. The number of disease-free years and the extra cost over and above maintenance treatment for both teeth and implants were recorded. RESULTS The sample consisted of 43 patients with an average age of 67.4 years. The patients had 847 teeth at the initial examination and received 119 implants. Two implants were removed 13 and 22 years after insertion. The prevalence of peri-implantitis was 53.5% at the patient level and 31.1% at the implant level. The prevalence of periodontitis was 53.4% at the patient level and 7.6% at the tooth level. The mean number of disease-free years was: implants: 8.66; neighbouring tooth: 9.08; contra-lateral teeth: 9.93. These mean values were not statistically significantly different from each other. The extra cost of maintaining the implants was about five times higher for implants than for teeth. CONCLUSION The number of disease-free years was the same for neighbouring teeth, contra-lateral teeth and implants. However, due to the high prevalence of peri-implantitis, the cost of maintaining implants was much higher than the cost of maintaining teeth.

Incentives and remuneration systems in dental services

The aim of this study was to examine the effects of an incentive-based remuneration system on number of individuals under supervision and on quality of public dental services in Norway. The basis for the study was a natural experiment in which all public dental officers in one county were given the opportunity to renegotiate their contract from a fixed salary contract to a combined per capita and fixed salary contract. Comprehensive data were collected before and after the change. A main finding is that the transition to an incentive-based remuneration system led to an increase in the number of individuals under supervision without either a fall in quality or a patient selection effect.

Perinatal mortality in non-western migrants in Norway as compared to their countries of birth and to Norwegian women

BackgroundA large number of women from countries with a high perinatal mortality rate (PMR) settle in countries with a low PMR. We compared the PMRs for migrants in Norway with the PMRs in their countries of birth. We also assessed the risk of perinatal death in offspring of migrant women as compared to offspring of Norwegian women.MethodsThe Medical Birth Registry of Norway and the Norwegian Central Person Registry provided data on births in Norway during the years 1986 to 2005 among all women born in Norway, Pakistan, Vietnam, Somalia, Sri Lanka, Philippines, Iraq, Thailand and Afghanistan. Information on the PMRs in the countries of birth was obtained from the World Health Organisation (WHO) for the years 1995, 2000 and 2004. Mean PMRs in Norway during 1986–2005 were calculated by mother’s country of birth, and the risks of perinatal death by country of birth were estimated as odds ratios (OR) using Norwegian women as the reference. Adjustments were made for mother’s age, plurality, parity, year of birth and gestational age at birth.ResultsThe PMRs for migrants in Norway were lower than in their countries of birth. The largest difference was in Afghan women (97 deaths per 1000 births in Afghanistan versus 24 deaths per 1000 births in Afghan women in Norway), followed by Iraqi and Somali women. As compared with Norwegian women, the adjusted odds ratio (OR) of perinatal death was highest for Afghan (OR 4.01 CI: 2.40 – 6.71), Somali (OR 1.83 CI: 1.44 - 2.34) and Sri Lankan (OR 1.76 CI: 1.36 – 2.27) women.ConclusionsThe lower PMRs for migrants in Norway as compared to the PMRs in their countries of birth may be explained by access to better health care after migration. The increased risk of perinatal death in migrants as compared to Norwegians encourages further research.

Cost-effectiveness of various treatment modalities for adult chronic periodontitis

The aim of this review was to assess the cost-effectiveness of various modalities for chronic periodontitis in adults. We searched the literature for studies where time consumption and monetary costs (where available) were used as expressions of the resources required to perform the following types of services: providing information on the disease and oral hygiene instruction for patients; removal of subgingival calculus; access surgery; and maintenance and prevention of recurrence of the disease. The following outcome variables were chosen: retention of teeth, or a surrogate variable such as change in bone level measured on X-rays taken at the start and at the end of a 1-year (or longer) period. The literature search did not reveal any studies where these outcome variables could be linked to information on resources used in treatment. Therefore, we reviewed relevant studies where different treatment techniques were used but where the outcome variables were different. This review revealed that in most cases it was difficult to assess whether one type of treatment (or intervention) is more effective than another. We conclude that better data are needed, in particular on outcomes, so that valid comparisons can be made between different types of treatment, for different types of studies. Periodontal disease is an inflammatory disease induced by bacterial plaque adhering to the tooth surface in contact with the gingiva. A lesion that is contained in the gingival margin is termed gingivitis. Gingivitis may be regarded as the result of an

Accessibility of dental services according to family income in a non-insured population

The aim of this study was to examine the effect of family income on accessibility to dental services among adults in Norway. The analysis was performed on a set of national data collected in 1989, which was representative of the non-institutionalized Norwegian population aged 20 years and above. The sample size was 1200 individuals. The data were analyzed according to a two-part model. The first part determined the probability of whether the consumer had demanded the services or not during the last year according to family income. The second part estimated how the amount of services utilized depended on family income, for those with demand. The elasticity of the odds of having demanded the services with respect to family income was 0.48. Family income had no effect on the amount of services utilized. Additional analyses also showed that there was no effect of family income on the probability of having received a filling or a crown when visiting the dentist. In Norway, almost all costs for dental services are paid by the consumer. It is not possible from the data alone to say whether subsidized dental care is an effective way of reducing the inequalities in demand.

Do expert patients get better treatment than others? Agency discrimination and statistical discrimination in obstetrics.

We address models that can explain why expert patients (obstetricians, midwives and doctors) are treated better than non-experts (mainly non-medical training). Models of statistical discrimination show that benevolent doctors treat expert patients better, since experts are better at communicating with the doctor. Agency theory suggests that doctors have an incentive to limit hospital costs by distorting information to non-expert patients, but not to expert patients. The hypotheses were tested on a large set of data, which contained information about the highest education of the parents, and detailed medical information about all births in Norway during the period 1967-2005 (Medical Birth Registry). The empirical analyses show that expert parents have a higher rate of Caesarean section than non-expert parents. The educational disparities were considerable 40 years ago, but have become markedly less over time. The analyses provide support for statistical discrimination theory, though agency theory cannot be totally excluded.