Trond Tjerbo

Does competition among general practitioners increase or decrease the consumption of specialist health care

Studies of the effects of capacity and competition among general practitioners (GPs) on the use of specialist health care services are inconclusive. Some studies indicate that an increase in the number of GPs leads to increased consumption of specialist health care, while other studies point in the opposite direction. This article adds to the literature in two ways; first by testing out different operationalization of capacity and competition among GPs, and then by testing out effects of capacity and competition on use of specialist health care services as this is disaggregated into ambulatory and inpatient activities. The empirical tests indicate that GP capacity in itself does not affect use of specialist health care services. Increased competitions among GPs do, however, reduce the use of ambulatory care while the effects on the use of inpatient services are unaffected.

The politics of local hospital reform: a case study of hospital reorganization following the 2002 Norwegian hospital reform

BackgroundThe Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives. The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector.MethodThe empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was one of the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies.ResultsThe analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo.ConclusionBecause of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arms length may simply be unrealistic and further complicate the politics of local hospital reforms.

The effects of the Norwegian Coordination Reform on the use of rehabilitation services: panel data analyses of service use, 2010 to 2013

BackgroundIn 2012 the Norwegian Coordination Reform was implemented. The main motivation was to encourage municipalities to expand local, primary health care services. From 2012 to 2014, under the Municipal Co-Financing regime, municipalities were obliged to cover 20 % of the costs of health services provided at the specialist (hospital) level. Importantly, use of rehabilitation services in private institutions was not part of the cost-sharing mechanism of Municipal Co-Financing. Rehabilitation services may be seen as quite similar in nature whether they be provided by municipalities, hospitals or private institutions. Thus, with rehabilitation patients readily “transferrable” between levels, the question is whether the reform brought with it a sought after shift towards more municipal rehabilitation and less specialist rehabilitation.MethodsData from the Norwegian Patient Register and from Statistics Norway/KOSTRA were utilized to gauge annual expenditures and inputs in specialist, municipal and private institution rehabilitation services respectively. Fixed effects and first difference regression analyses for the period 2010–2013 were carried out to account for certain time-invariant traits of municipalities and/or hospital regions, and results were adjusted for contemporaneous trends in local needs.ResultsExpenditures in specialist rehabilitation services declined sharply (typically by 8–10 %) from 2011 (pre-reform) to 2012 (post-reform), while expenditures in private rehabilitation services rose markedly in the same period (typically by 42–44 %). The results do not suggest any general expansion of municipal rehabilitation services.ConclusionsThe results of the analyses suggest that municipalities shift away from the use of specialist rehabilitation services and towards the use of rehabilitation services in private institutions since the latter becomes relatively cheaper (free-of charge) than both municipal and specialist services in post-reform periods (as specialist services come at a cost to municipalities post-reform). While the main goal of the reform has not materialized the results nevertheless suggest that incentives (of cost-shifting) do play a significant role in rehabilitation service use.

The role of young users in determining long-term care expenditure in Norway

Aims: In Norway, it is the responsibility of the country’s 429 municipalities to provide long term care (LTC) services to their residents. Recent years have seen a sharp rise in the number of LTC users under the age of 65. This article aims to explore the effect of this rise on LTC expenditure. Methods: Panel data models are used on data from municipalities from 1986 to 2011. An instrumental variable approach is also utilized to account for possible endogeneity related to the number of young users. Results: The number of young users appears to have a strong effect on LTC expenditure. There is also evidence of municipalities exercising discretion in defining eligibility criteria for young users in order to limit expenditure. Conclusions: The rise in the number of young LTC users presents a long-term challenge to the sustainability of LTC financing. The current budgeting system appears to compensate municipalities for expenditure on young LTC users.

Elderly Demand for Family-Based Care and Support: Evidence from a Social Intervention Strategy

This paper examines the influence of the national health insurance scheme on elderly demand for family-based care and support. It contributes to the growing concern on the rapid increase in the elderly population globally using micro-level social theory to examine the influence the health insurance has on elderly demand for family support. A qualitative case study approach is applied to construct a comprehensive and thick description of how the national health insurance scheme influences the elderly in their demand for family support. Through focused interviews and direct observation of six selected cases, in-depth information on primary carers, living arrangement and the interaction between the health insurance as structure and elders as agents are analyzed. The study highlights that the interaction between the elderly and the national health insurance scheme has produced a new stratum of relationship between the elderly and their primary carers. Consequently, this has created equilibrium between the elderly demand for support and support made available by their primary carers. As the demand of the elderly for support is declining, supply of support by family members for the elderly is also on the decline.

The health policy pendulum: Cost control vs. activity growth*

BACKGROUND Cost containment is a major policy challenge and one of the key drivers of health care reform. In this article, we focus on the role cost control has played as a reform driver in the Norwegian hospital sector between 1980 and 2014. METHODS We use data on aggregate expenditure as well as on activity changes from year to year. We also use qualitative data for illustrative purposes. RESULTS We identify 4 phases in the period 1980 to 2014: two where activity increases have dominated the agenda and 2 where cost control has been emphasized. The desire to either increase activity or improve cost control has been important reform drivers. CONCLUSION Cost control has been a major reform motivator in the period, and some of the policies aimed towards achieving cost control have been successful. But as cost control is achieved, waiting lists and popular dissatisfaction increase and new policies are implemented to increase activity.