Tor Iversen

THE EFFECT OF A PRIVATE SECTOR ON THE WAITING TIME IN A NATIONAL HEALTH SERVICE

This article examines the effect of a private sector on the waiting time associated with treatment in a public hospital. Without rationing of waiting-list admissions, a private sector is shown to result in a longer waiting time if the demand for a public treatment is sufficiently elastic with respect to the waiting time. When waiting-list admissions are rationed, the waiting time is shown to increase if the public sector consultants are permitted to work in the private sector in their spare time.

A theory of hospital waiting lists

The noncooperative character of resource allocation in a national health service may contribute to excessive waiting lists. A theory of hospital waiting lists is derived from this idea. Waiting lists imply loss of efficiency; the hospitals resources are drawn away from medical work. Although there is scope for Pareto improvements, the structure of budget allocation may prevent these improvements from being achieved. Some reforms of the institutional structure are suggested.

The Effect of Activity-Based Financing on Hospital Efficiency: A Panel Data Analysis of DEA Efficiency Scores 1992-2000

Activity-based financing (ABF) was implemented in the Norwegian hospital sector from 1 July 1997. A fraction of the block grant from the state to the county councils has been replaced by a matching grant depending upon the number and composition of hospital treatments. As a result of the reform, the majority of county councils have introduced activity-based contracts with their hospitals. This paper studies the effect of activity-based funding on hospital efficiency. We predict that hospital efficiency will increase because the benefit from cost-reducing efforts in terms of number of treated patients is increased under ABF as compared with global budgets. The prediction is tested using a panel data set from the period 1992–2000. Efficiency indicators are estimated by means of data envelopment analysis (DEA) with multiple inputs and outputs. Using a variety of econometric methods, we find that the introduction of ABF has improved efficiency when measured as technical efficiency according to DEA analysis. The result is less uniform with respect to the effect on cost-efficiency.

The Norwegian Health Care System

This paper examines the Norwegian health care system from an economic perspective. While acknowledging the excellent quality of services delivered by the Norwegian health care system, it identifies a number of problem areas, in particular: i) the long waiting lists for hospital admission and lack of medical staff; ii) the marked regional variation in per capita health care expenditure (which cannot be fully explained by demographic factors); and iii) the risks to cost control associated with soft budget constraints and collective wage bargaining of doctors. A series of recent reforms, most importantly a move from block grant to activity-based funding of hospitals, should provide incentives for raising efficiency in health care provision but also risk leading to “treatment inflation” ... Cet article examine le systeme norvegien de soins de sante d’un point de vue economique. La qualite excellente des services fournis par le systeme norvegien de soins de sante est reconnue, neanmoins l’article identifie un certain nombre de secteurs a probleme, en particulier : i) les longues listes d’attente pour l’admission en hopital et le manque de personnel medical ; ii) la forte disparite regionale dans les depenses de soins de sante par habitant (qu’on ne peut pas expliquer totalement par des facteurs demographiques) ; iii) les risques lies a la maitrise des couts associes a des contraintes budgetaires faibles et les negociations salariales collectives des medecins. Plusieurs reformes recentes, la plus importante etant le remplacement des dotations globales par un systeme de financement en fonction de l’activite, devraient fournir des incitations pour accroitre l’efficience des services fournis mais risquent aussi de conduire a une “inflation des traitements” ...

Economic motives and professional norms: the case of general medical practice

Professional norms are supposed to have a central role in the allocation of resources when consumers have inferior information about the characteristics of products. We argue that economic motives are nevertheless important to resource allocation when professional opinions differ. The argument is illustrated with an example from medical care. We find that physicians who experience a shortage of patients have higher income, longer and more frequent consultations and more laboratory tests per listed person than their unconstrained colleagues.

Health care performance comparison using a disease-based approach: The EuroHOPE project

This article describes the methodological challenges associated with disease-based international comparison of health system performance and how they have been addressed in the EuroHOPE (European Health Care Outcomes, Performance and Efficiency) project. The project uses linkable patient-level data available from national sources of Finland, Hungary, Italy, The Netherlands, Norway, Scotland and Sweden. The data allow measuring the outcome and the use of resources in uniformly-defined patient groups using standardized risk adjustment procedures in the participating countries. The project concentrates on five important disease groups: acute myocardial infarction (AMI), ischemic stroke, hip fracture, breast cancer and very low birth weight and preterm infants (VLBWI). The essentials of data gathering, the definition of the episode of care, the developed indicators concerning baseline statistics, treatment process, cost and outcomes are described. The preliminary results indicate that the disease-based approach is attractive for international performance analyses, because it produces various measures not only at country level but also at regional and hospital level across countries. The possibility of linking hospital discharge register to other databases and the availability of comprehensive register data will determine whether the approach can be expanded to other diseases and countries.

Genetic testing when there is a mix of compulsory and voluntary health insurance

When the insurer has access to information about test status, genetic insurance can handle the negative effects of genetic testing on insurance coverage and income distribution. 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.

An exploratory study of associations between social capital and self-assessed 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 standard-of-living survey 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 persons 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 -- is 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 no effect in the panel survey, we find that sports organizations have a negative effect on health in the cross-sectional survey and no effect in the panel survey. The question is raised whether the welfare state diminishes the effect of structural community social capital, as represented by voluntary organizations, on health.

Waiting time as a competitive device: an example from general medical practice.

From a theoretical model we predict that only physicians with quality characteristics perceived as inferior by patients are willing to embark on waiting time reductions. Because of variation in these quality characteristics among physicians, market equilibrium is likely to show a range of waiting times for physician services. This hypothesis is supported by results from a study of Norwegian general practitioners. Since the waiting time offered by a physician influences the number of patient-initiated consultations, a policy implication of our study is that the distinction between patient-initiated and physician-initiated consultations may be less clear-cut than often assumed in the literature.

Scandinavian Long-Term Care Financing

In this paper, we compare and analyse the systems for financing long-term care for older people in the Scandinavian countries – Denmark, Norway and Sweden. The three countries share common political traditions of local autonomy and universalism, and these common roots are very apparent when the financing of long-term care is concerned. Nevertheless, the Scandinavian systems for long- term care (LTC) exhibit some important deviations from the idealized “universal welfare state” to which these countries are normally ascribed. For example, user charges tend to be strongly dependent on earnings, which is incoherent with the general norm of flat-rate public services. Also, there is significant regional variation in the level of services provided, which is in direct contrast with the universalist ambitions. Overall, the Scandinavian countries distinguish themselves through their very high reliance on public spending in long-term care. It is unclear to what extent the Scandinavian model for financing of long term care will be sustainable as demographic change progresses in the next few decades.