Nordic Journal of Health Economics

Advancing and Inspiring Health Economics: A Special Issue in Honor of Tor Iversen

ELINE AAS — 2023-12-21

Professor Tor Iversen is a distinguished and highly respected health economist who has made significant contributions to the field of health economics. With this special issue, we celebrate his work.

The Role of Health Status and Social Capital in Cancer Mortality:

Geir Godager — 2023-12-21

Abstract: Cancer mortality has been shown to be associated with social- and human capital. Several channels have been suggested, such as early detection, better compliance to treatment and better health prior to diagnosis. In this paper we study how health status and social capital jointly affect cancer mortality and cancer severity at the time of diagnosis. The analyses are based on study sample of individuals with cancer diagnosis. Our merged dataset contain information on cancer diagnosis and death from the Cancer Registry of Norway and health status, social capital and other individual level data from several national health surveys measured before the time of diagnosis. Health status and social capital are treated as unobserved latent variables, and we apply generalized structural equation modelling framework to estimate conditional statistical associations of social capital and individual health on cancer severity and mortality. We find that health has negative, and statistically significant effect, on cancer mortality, while we cannot conclude on the association between health and cancer severity (metastasis yes/no). We cannot conclude that cancer mortality and the probability of cancer metastasis is associated nor disassociated with social capital. Our results add nuance to prior studies, which frequently report a significant association between social capital and cancer mortality.

Mortality and subsequent healthcare use among older patients discharged to a municipality with excess demand for elderly care

Gudrun Bjørnelv — 2023-12-21

There is limited knowledge on how excess demand for elderly care influences patient outcomes. We used a natural experiment to estimate the causal effect of discharging elderly patients from hospital to municipalities with excess demand. In Norway, hospital in-patients are defined as ready-for-discharge when hospital treatment is completed, but the patient needs further care from municipal services. After this, the municipality of residence is obliged to either provide care for the patient or to pay the hospital a fixed fee per day that the patient spends in hospital. Municipal fee-days may thus indicate excess municipal demand. In the current paper, we studied how excess municipal demand, indicated by the number of fee-days accumulated in the municipality 30 days before an acute admission, influenced patient outcomes. To minimize confounding, we compared patients living within the same municipality, admitted during the same type of day, in the same year, but with varying excess demand. Our outcomes were mortality, resource use and healthcare costs at the primary and secondary care level, within 30 days. Between 2012 and 2016, 354,834 individuals (age≥70 years) had a total of 895,892 acute admissions. There was a 2% increased 30-day mortality per standard deviation change in accumulate fee-days (Hazard ratio (HR) of 1.02, 95% confidence interval (CI) 1.01-1.03). Individuals living in small municipalities (population<10,000) had HR of 1.04, (95% CI 1.02-1.07), while individuals living in larger municipalities (population>10,000) had HR of 1.01 (95% CI 1.00-1.03). We found no substantial effect on subsequent healthcare use or costs. Relevance tests supported that fee-days was a good indication of excess demand, and balance tests supported that patients were comparable between periods with different excess demand. In conclusion, our results imply that older patients who are discharged to a municipality with excess demand have slightly elevated mortality, particularly in small municipalities.

Ex-ante and ex-post regulation: Does the joint use improve on social welfare?

Sverre Ole Grepperud — 2023-12-21

A principle-agent model is applied to discuss the relationship between ex-ante regulation (standards) and ex-post regulation (firm and worker fines). Accident risks (e.g. medical errors) are affected by decisions made both by the firm (hospital) itself and the employees of the firm (healthcare workers), the regulator observes the safety efforts of the firm and (a share of) the occurrences of accidents, while worker safety efforts are non-contractible. We find that standards and firm fines are substitutes since their joint use does not improve social welfare relatively to their exclusive use. However, standards and worker fines become complements (the joint use improves social welfare relative to their exclusive use) in the presence of firm-related accident costs.

Nordic Academic Publishing in Health Economics

Martin Karlsson Karlsson — 2023-12-21

We analyse how the Nordic contribution to health economics has evolved over the past three decades -- in quantitative and qualitative terms. Using a dataset of publications from five prominent field journals for health economics, we combine different empirical methods to analyse the general trends in terms of number of distinct publications, topics covered, and co-authorship relationships between countries and individuals. We find that the Nordic countries are responsible for a stable share of international publications in health economics. The topics that Nordic health economists publish on are relatively similar to those most prevalent in the international community, even though health insurance is remarkably absent as a research topic in Nordic countries. In terms of links between countries and co-authors, we see that Nordic researchers are well embedded in the international community, and that the Nordic research community has moved toward less hierarchical relationships.

20 years of Nordic comparative health economics research

Sverre A.C. Kittelsen — 2023-12-21

Nordic comparative health economics research stands out internationally both by its access to excellent patient data and its long-time commitment to rigorous analyses. In this article, we present the methodological foundations and the results from two types of performance analyses – comparative analyses of health care outcomes and costs at hospital level and similar analyses at the disease level. In the concluding part, we discuss strength and weaknesses of the Nordic comparative analyses, and how we should develop Nordic comparative health economics research further.

Future disease-specific health spending and burden of disease in Norway, 2019 to 2040

Jonas Minet Kinge — 2023-12-21

The expected increase in the proportion of elderly, with increasing rates of chronic diseases, presents a challenge to the Norwegian healthcare system. In this study, we project the future burden of disease and health spending by health conditions from 2019 to 2040; and explore the importance of 1) population growth, 2) population composition, and 3) future epidemiological development for these projections. We find that total, and per capita, health spending is projected to increase in three scenarios (reference, better and worse health) from 2020 to 2040 for communicable diseases, non-communicable diseases, and injuries. The increased proportion of elderly drives the increase in health spending. When keeping the age composition constant (and by this account for the increased proportion of elderly), we find that per capita health spending decreases in the reference and better health scenario but not in the worse-health scenario. If Norway aims to provide care at current levels in the future, substantial reductions in the cost of care is needed. If not, increased health spending is inevitable, due to chronic conditions in old age.

Healthy aging and future health spending

Hans Olav Melberg — 2023-12-21

This article examines the extent to which differences in life-expectancy are associated with shifts in average hospital costs for different age groups. The effect of increases in life expectancy on the cost curves is identified by comparing two countries with different life expectancies, but which are very similar on other variables like culture, technology and health systems (Norway and Denmark). Using data from the National Patient Registries the paper compares the ratio of average spending on individuals who die and individuals who survive in different age groups in these two countries. The best fit between the age related cost curves is achieved when the cost curve in the country with a two year longer life expectancy is also shifted by two years.

Innovations in use of registry data (INOREG)

Tron A. Moger — 2023-12-21

Abstract: In recent years there have been several political initiatives in Norway, requiring more research into how multimorbidity and health care pathways in the municipality affect outcomes such as work participation, hospital admissions, disability and quality of life for patients with chronic diseases. Most of the care is provided outside hospitals and has been difficult to capture in large, registry-based studies. Focusing on two important groups, patients with chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders (MSD), the INOREG project aims to reduce these knowledge gaps. In the paper we present 1) the data that are used in the project, 2) the construction of samples, variables and possible methods for analysis and 3) an example on how the data and methods will be applied. The project database is constructed from a novel linkage of national health and welfare registries. The data cover social, primary and specialized care for all COPD and MSD patients in Norway, long-term care data from Oslo and Trondheim municipalities and functioning and quality of life for ca. 2,700 patients treated at physiotherapy clinics in the FYSIOPRIM project. This enables construction of care pathways and outcomes at the individual level from 2008 through 2019. The project will fill knowledge gaps regarding the patterns of care at different levels in the health care system, and the association to outcomes for chronic patient groups. If the project is successful, it will provide improved insight on how to further develop provision and coordination of services to the decision makers, and ideally reduce inequalities in health.

List size disequilibria and service provision in general practice

Kim Rose Olsen — 2023-12-21

Abstract: Several Nordic countries remunerate general practice by a mix of capitation and fee-for-service. From the literature we know that capitation-based payments come with a risk of undersupply of services, whereas fee-for-service comes with a risk of overprovision of services. Previous studies from the Nordic countries assess potential overprovision of services in general practices that are falling short of enlisted patients. However, today the main challenge in general practice is physician shortages, which comes with a risk of underprovision of services. Little is known about whether physician shortage in fact leads to underprovision of services. Using the two-way Mundlak regression on a panel of Danish general practices in 2016-17, this study assesses whether holding a longer than preferred patient list is associated with fewer services per enlisted patient. Around 100 of our sample of 1,652 practices hold longer lists than preferred. These practices have on average an excess of around 80 patients per full time general practitioner. We find little support of the hypothesis that practices with longer than preferred lists provide fewer contacts per patient. Heterogeneity analyses, however, reveal that practices with longer lists tend to provide fewer services to patients with complex needs. Policymakers should therefore be aware that there may be underprovision of services to high-need patients when there is a shortage of GPs.

A Review of Policies to Reduce Waiting Times for Health Services across OECD Countries

Luigi Siciliani — 2023-12-21

Waiting times for health services are a significant policy issue in most OECD countries, where improving the experience and patient satisfaction with the health system is a key objective. Waiting times in publicly-funded systems arise from the imbalance between demand for and supply of health services. This study reviews policies aimed at reducing waiting times in OECD countries across different health services: specialist consultations and elective treatments; consultations with primary care providers; cancer care; and mental health services. A policy questionnaire was sent by the OECD in May 2019. For each area it asked information on a) policies, its objectives and actions, b) the extent to which they were regularly evaluated or assessed, and c) main results of the evaluation. 33 countries provided at least a partial response, with 24 countries providing detailed information about the policies, which are reviewed in this study. Our key findings are as follows. Countries often start by specifying maximum waiting times across a range of services, which can be used as a guarantee for patients and/or targets for providers. Policies for elective care include improving demand management by prioritising patients on the list, and improving coordination between primary and secondary care. For primary care, policies focus on increasing the supply of general practitioners and advanced practice nurses, and encouraging the use of new technologies (e.g. teleconsultations). For cancer care, countries have developed national strategies to ensure timely access to diagnosis and treatment, including fast-track pathways, which rationalise and coordinate different types of cancer services, facilitated by dedicated capacity. Policies for mental health focus on better meeting demand through increased volume or scope with, in some cases, targets driving better access. In summary, policymakers have several levers to reduce waiting times along the patient pathway to improve responsiveness and make health systems more people centred.

Does gender affect medical decisions?

Geir Godager — 2023-12-21

It is rarely the case in medical practice that differences between female and male physicians can be described under ceteris paribus conditions. Physicians self-select their type of practice, patients self-select physicians, and physicians are expected to account for both the context and the characteristics of their patients when providing medical treatment. As a result, reported gender differences in medical practice can have several alternative interpretations. A key question, therefore, is whether
the treatment of a given patient is expected to depend on the gender of the physician. To address this question, we quantify gender effects using data from an incentivized laboratory experiment, in which Chinese medical doctors and Chinese medical students choose medical treatment under different payment schemes. We estimate preference parameters of females and males assuming decision makers have patient-regarding preferences. We cannot reject the hypothesis that gender differences
in treatment choices are absent. The differences between preference parameters of females and males are not statistically significant, and there is no evidence that the degree of randomness in choices differs between genders. The absence of gender effects in the laboratory, where choice context is fixed, provides nuance to previous findings on gender differences, and highlights the general difficulty of separating individuals’ behavior from their context.