Pål E. Martinussen

Reimbursement systems, organisational forms and patient selection: evidence from day surgery in Norway

Cream skimming can be defined as the selective treatment of patients that demand few resources while providing high economic refunds. We test whether cream skimming occurs after the introduction of DRG-based activity-based financing (ABF) in Norway in 1997 and if the problem further increased after the 2002 organizational reform when hospitals were turned into trusts. The DRG-system offers the same economic reimbursement for patients classified within day-surgical DRGs irrespective of whether the patient receives same-day treatment or in-patient care over several days. This provides potential for cream skimming and allows us to investigate cream skimming within the actual diagnoses. Patient data from the period 1999-2005 is analyzed. Waiting times are used as indicators of patient selection and analyzed as a function of severity within each diagnosis, controlling for age and gender of the patient, as well as institutional and time-dependent variables. The analysis gives some evidence of cream skimming in the first period of ABF, in particular within the lighter orthopaedic diagnoses. However, cream skimming does not increase after the 2002 organizational reform but is stable, and for some DRGs even reduced. The study indicates that cream skimming may occur if reimbursement systems are not particularly sophisticated. Softening of budget constraints after the hospital reform of 2002 may explain why cream skimming does not increase after the reform. However, further investigation into this mechanism is needed.

Referral quality and the cooperation between hospital physicians and general practice: the role of physician and primary care factors.

Aims: It has been shown that referral letters from GPs often are of poor quality, but research in this field is scarce, and few efforts have been made to investigate the factors that may help explain the variation in referral quality. Methods: Combining a survey among 1298 Norwegian hospital physicians (response rate: 52%) with information on the hospitals and the communities they are serving, this study investigates how they view the general quality of patient referrals received from GPs, and the extent to which insufficient information in referrals and inappropriate referrals is considered a problem for cooperation with GPs. Results: Only 15.6% of the hospital physicians perceived the quality of the referrals to be “usually good”, and both lack of information in referrals and inappropriate referrals are seen as important barriers to cooperation with GPs. Of the individual factors, former GP practice is associated with a positive view on referral quality, while regular meetings between hospital physicians and GPs seem to reduce the problems of inappropriate and incomplete referrals. Furthermore, both average number of patients on GPs’ lists and lack of free capacity in nursing and care institutions in the hospital catchment area was found to be negatively associated with perceived referral quality. Conclusions: There is a need to increase the knowledge on how contextual, institutional and professional factors affect coordination of care. The main contribution of this study lies in the attempt to address the macro and micro barriers of obtaining good referral care.

In Search of the Government in Local Government: Coalition Agreements and Office Payoffs in Norway

The politics of European local government is often assumed to take place in a rather depoliticised and non-partisan environment. This feature is especially apparent in Norway, where local government institutions are designed to create a high degree of consensus and accommodation. No local cabinet takes office, and therefore no formal roles of a majority government and an opposition are offered. This paper tells a different story, however. Following the 1999 elections many municipalities are now experiencing partisan cooperation based on binding political agreements. In these cases the common practice of proportional distribution of the important political positions is replaced with a ‘winner takes all’ principle, as only the majority constellation is rewarded with office payoffs. Given that this form of cooperation is the closest analogue to any cabinet formation at the local level, it is clearly of interest to uncover under which conditions it occurs. The empirical analysis therefore uses variation in structural, socioeconomic and political characteristics to predict the local coalition behaviour. The empirical model captures some important determinants in the variation of structural characteristics, and, as expected, explicit and binding coalition agreements are found in the large and central municipalities. Socioeconomic setting is furthermore important, since municipalities with a high degree of financial autonomy and poor policy performance experience this kind of formalised cooperation more frequently. Systematic effects are also found for political characteristics, with electoral volatility, party fragmentation and functional organisation models all increasing the probability of coalition agreements.

The geography of chronic obstructive pulmonary disease: A population-based study of Norway

Research on chronic obstructive pulmonary disease (COPD) that includes geographic information is important in order to improve care and appropriate allocation of resources to patients suffering from COPD. The purpose of this study is to investigate the geography of COPD and factors associated with the spatial patterns of COPD prevalence. Particular emphasis is put on the role of the local socioeconomic environment. Utilising information from the Norwegian Prescription Database on all lung medication prescribed in 2009 we identified 62,882 persons with COPD in the Norwegian population. Patterns of spatial clustering in the prevalence of COPD are clearly evident, even when age and gender are controlled for. Gender and age are strongly related to COPD risk. Socio-economic characteristics of the community such as education and unemployment are also significantly correlated with COPD risk. People living in rural parts of the country are generally associated with less risk than people in urban settings, and in particular people living in communities with high levels of farm and fisheries employment.

Linking Coalitions to Policy Output: The Case of Local Government in Norway

The main emphasis in coalition studies has so far been on national coalitions—with the local level being rather overlooked—and in most studies estimating the impact of local politics researchers have used various indicators of the electoral strength of parties as their main political variable. In this analysis we investigate the genuine composition of coalitions in each and every municipality in Norway, describing which parties serve as the majority base for the mayor and the deputy mayor. This approach gives us the opportunity to investigate both the impact of the genuine political office holders, as well as the structural properties of coalitions, on policy output. Using a decomposition of school expenditure suggested by Falch and Ratts0, we are able to ask in what ways money is spent inside the sector, in addition to how much money is spent. The empirical results show that coalitions can be linked to policy output; the preferred spending objects vary both according to the parties forming the coalition and the structural composition of the coalition.

Benzodiazepine use in COPD: empirical evidence from Norway.

Background The common comorbidities associated with COPD include, among others, anxiety, depression, and insomnia, for which the typical treatment involves the use of benzodiazepines (BZD). However, these medicines should be used with extra caution among COPD patients, since treatment with traditional BZD may compromise respiratory function. Aims This study investigated the use of BZD among persons suffering from COPD by analyzing three relevant indicators: 1) the sum of defined daily doses (DDD); 2) the number of prescribers involved; and 3) the number of different types of BZD used. Data and methods The study builds on a linkage of national prescription data and patient–administrative data, which includes all Norwegian drug prescriptions to persons hospitalized with a COPD diagnosis during 2009, amounting to a total of 5,380 observations. Regression techniques were used to identify the patients and the clinical characteristics associated with BZD use. Results Of the 5,380 COPD patients treated in hospital during 2009, 3,707 (69%) were dispensed BZD during the following 12 months. Moreover, they were dispensed on average 197.08 DDD, had 1.22 prescribers, and used 0.98 types of BZD during the year. Women are more likely to use BZD for all levels of BZD use. Overnight planned care not only increases the risk of BZD use (DDD), but also the number of prescribers and the types of BZD in use. Conclusion In light of the high levels of BZD prescription found in this study, especially among women, it is recommended that general practitioners, hospital specialists, and others treating COPD patients should aim to acquire a complete picture of their patients’ BZD medication before more is prescribed in order to keep the use to a minimum.

Public evaluation of health services across 21 European countries: The role of culture:

Aims: This work examined the role of cultural values in understanding people’s satisfaction with health services across Europe. Methods: We used multilevel linear regression analysis on the seventh round of the European Social Survey from 2014, including c. 40,000 respondents from 21 countries. Preliminary intraclass correlation analyses led us to believe that some explanations of variance in the dependent variable were to be found at the country level. In search of country level explanations, we attempted to account for the role of national culture in influencing citizens’ attitudes towards health systems. This was done by using Hofstede’s dimensions of power distance, individualism, masculinity and uncertainty avoidance, giving each country in the survey a mean aggregated score. Results: In our first model with individual level variables, being female, having low or medium education, experiencing financial strain, and reporting poor health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems, with the latter variable showing the strongest effect. After including Hofstede’s cultural dimensions in our multilevel model, we found that the power distance index variable had a negative effect on the dependent variable, significant at the 0.1 level. Conclusions: Citizens are likely to evaluate their national health system more negatively in national cultures associated with autocracy and hierarchy.

Treatment Outcomes Among Individuals in a Musculoskeletal Pain Rehabilitation Program Related to the Prevalence and Trends in the Dispensing of Prescribed Medications

Abstract Objectives: Prescribed medication consumption for chronic, non-malignant pain may not be beneficial. This study investigated how self-reported treatment outcomes among individuals in a musculoskeletal pain rehabilitation program are related to the prevalence and trends in the dispensing of prescribed medications. Methods: Patients with musculoskeletal pain were recruited as they began a rehabilitation program. Each participant completed a self-administrated questionnaire on pain, health status and socioeconomic factors in the beginning and at the end of the rehabilitation period. Each individual’s baseline data from the rehabilitation sample was linked to the national Norwegian Prescription Database [2004–2010]. Dispensing prescribed medications in the groups of centrally acting analgesics [opioids], anxiolytics and hypnotics were studied. Results: A total of 1562 individuals participated, and there was no loss to follow-up. Controlled medications [Schedule 2] were prescribed in 36.4% [n = 569] of the sample population. Women were overrepresented in the sample. The dispensing of prescribed hypnotics is more frequent than the dispensing of prescribed analgesics and anxiolytics. Old age, low education level and living alone are related to being prescribed hypnotics and anxiolytics, while gender [female] is related to being prescribed analgesics. A reduction in pain intensity over the two observations in time [pre- and post-treatment] is related to the prescription of hypnotics, while a lack of improvement in physical capacity during the rehabilitation program is significantly related to being prescribed analgesics. The improvement in overall health is significantly related to being prescribed anxiolytics. Conclusions: Dispensing of prescribed analgesics, anxiolytics and hypnotics among individuals in rehabilitation with chronic musculoskeletal pain is associated with treatment outcomes and should be taken into account in designing the rehabilitation intervention.

Response to Karlberg's comments on ``Hospital waiting time in Norway: What is the role of organizational change?''

Karlberg provides a critique of our article, raising serious points about whether waiting time is an interesting subject for research and analysis. We are glad to have the opportunity to provide our thoughts on Karlberg’s reflections. The point of departure for our study is the recognition that Norwegian health authorities have increased the focus on waiting lists and waiting time for elective treatment, and placed reduction of waiting time high on the political agenda [e.g. 1,2]. Government white papers furthermore reflect a belief that internal reorganisation of the hospital organisations may contribute to a reduction of waiting time [e.g. 1,3]. The assessment of two such reorganization efforts – ring-fencing of elective surgery and activity-based budgets at departmental level – is the subject of our analyses. Hence, whether waiting time is a good or poor indicator of medical needs and demand satisfaction in the population is not the focus of our article. We simply recognize the political emphasis on waiting time and the initiatives suggested to reduce the time patients are waiting. Given that Karlberg’s main argument seems to be that reductions of waiting time per se should not be integrated in the goal structure of any national health system, we suspect that Karlberg’s comment should rather be addressed to Norwegian health politicians than to us. We would, however, like to point to some research contributions that have documented the importance of waiting time for significant outcome measures such as patient satisfaction [e.g. 4], medical, personal, and societal costs, and deterioration in physical functioning while waiting [e.g. 5]. Furthermore, given that the medical specialists must be expected to follow the centrally decided priority instructions, our analyses are based on the assumption that indications for treatment vary only marginally between hospitals. To suggest otherwise would be rather controversial. Finally, Karlberg also argues that ‘‘the inflow of new patients is dependent on several issues: the size and demography of the target population, the culture relating to demands in the population, the geographical circumstances, the medical needs for healthcare (not necessarily health!), and indications for treatment at the unit where treatment is supposed to be performed’’. If Karlberg reviews our article in more detail, he will see that we control for several of these aspects in our analysis, such as elderly share and local living conditions.

From Centralization to Decentralization, and Back: Norwegian Health Care in a Nordic Perspective

In the Nordic countries, health care is an integral part of what is often termed the Scandinavian (or Nordic) model of the welfare state (Esping-Andersen 1990). Thus, health care is generally seen as a public responsibility, with universal access, negligible user fees, and a strong focus on equity (Martinussen & Magnussen 2009). In this chapter we discuss the Nordic model of health care primarily by focusing on one country, Norway.We also highlight similarities and differences between Norway and the other Nordic countries. While Norway is a small country in terms of population, it covers a large area and thus geographical equity is an important issue. This is reflected throughout the system; in structural issues, in choice of (political and administrative) governance models, and in choice of financing system. Although Norway, as are the other Nordic countries, is characterized by a tradition of locally elected governments (municipalities and counties), health policy and healthcare reforms in the past 15 years serve as illustrations of the potential conflicts between public articipation, local governance, and a stated goal of national equity.