Sweden adopted a softer public health COVID-19 strategy than most countries by relying on recommendations rather than restrictions. Here we focus on the effects of this choice on the economy (GDP), number of deaths and severe illnesses by comparing Sweden to a comparison group consisting of Denmark and Norway, two countries similar in many aspects to Sweden but that have differed from it in terms of COVID strategies. The Swedish policy resulted in a net loss of USD 27.3 billion (USD 2,650 per capita) stemming mostly from relative loss in GDP (83% of total). Our findings suggest that the costs of the strategy in the form of (monetized) excess deaths and severe illness cannot be justified by benefits in the form of a better economic performance.
Primary care in the Nordic countries have many similarities but are also different in crucial ways (Olsen et al. 2016). Among the similarities are that Nordic primary care is tax-based, aims to ensure equal and easy access to care for all citizens, and supply high-quality care at the lowest cost-effective level. Among the differences are the Nordic countries’ way of organizing primary care with respect to remuneration, incentives, and the use of general practitioners (GPs) as gatekeepers. As other countries, the Nordic countries have experienced certain challenges in primary care in recent years. Demands from patients and third-party payers are increasing both with respect to quantity and quality of services expected for provision. Some of the reasons for this are ageing populations, more patients with chronic diseases, and third-party payers aiming to make primary care the main responsible for prevention and treatment of the chronically ill. At the same time, the supply of GPs continues to drop (especially in Denmark and Norway and with Finland as an exception), the share of avoidable hospital admissions of all hospital admissions is still too high, and the same holds for the share of inappropriate antibiotic prescriptions in primary care (OECD 2020). There is therefore still room for improvement, although primary care in the Nordic countries overall tend to be placed in the better half of the distributions compared to other OECD countries. In the 2020 OECD report on the potential of primary health care, several actions were outlined that could help strengthen the efficiency, effectiveness, and access of primary care. To improve the efficiency of primary care, new recruitment and training strategies, better use of digital technology, and providing the right (financial) incentives were pointed out as potential tools. To improve the effectiveness and responsiveness of primary care, reorganization in teams and integrated networks, bundled payments, and improved information systems were pointed out as possible solutions. To improve access and equity in primary care, it was recommended to use technology and mobile clinics to reach rural areas, in occupational health in workplaces, and to revisit the roles of health care professionals (OECD 2020). In this special issue in the Nordic journal of health economics, several studies from the Nordic countries focus on the challenges in Nordic primary care in different ways. The issue includes empirical studies from Sweden, Norway, Denmark, and Finland, as well as a theoretical contribution concerned with recruitment and retention in Nordic primary care. The studies all factor into the recommendations made in the OECD report on how to strengthen primary care. For example, in this special issue we will learn in a study by Glengård that characteristics that can be changed by primary care clinics themselves, such as division of labour and continuity of care are also the most important for patients’ experience of care relative to factors that are out of the primary care clinics’ control. On the positive side, this means that there is scope for improvements while on the negative side, improvements may be difficult due to challenges with GP shortages in Sweden, where the study was conducted. Oxholm and colleagues are also concerned with the GP shortage issue and study the link between work pressure in general practice and job dissatisfaction of GPs. They find that the link between experienced work pressure and job dissatisfaction is stronger for GPs working in areas with an undersupply of GPs and for GPs in singlehanded practices. These areas could therefore be of special interest to policy makers when implementing new incentive schemes and structures affecting GPs’ work pressure. While reorganising primary care may be part of the solution to overcome the challenges in primary care, Aars and Kaarbøe offer insights into the recruitment and retention of GPs in a theoretical model to inform policy decisions. They show that there are conflicting effects as policies that have a positive effect on recruiting and retaining GPs can have a negative effect on GPs’ effort and services and that the effect is sensitive to GPs’ degree of altruism. In a study by Snilsberg, who is concerned with how new team-based primary care delivery models in Norway can be effectively evaluated when there are potential issues with selection bias and small sample sizes, we learn that matching methods can be used to account for these issues and propensity score weighting is suggested. The paper also identifies several important predictors for joining the new primary care delivery models. Holster and colleagues are interested in how occupational healthcare in Finland is used and how the use is associated with other ambulatory service sectors and the distribution of care between these. Interestingly they find that the use of occupational healthcare seems to be associated with higher use of ambulatory care services overall, which suggests that ambulatory care is not allocated according to need. This raises important questions of equality in access to care. Focusing on the challenges in Nordic Primary care from a health economic perspective is a first step towards understanding the mechanisms behind the problems. The health economics discipline and its tools can help uncover the issues and disclose where to set in to solve the problems. It can also explore the potential of the OECD recommendations in more detail and elicit in what areas the greatest potential is for improving efficiency, effectiveness, and equity. Recommendations for important next steps to solve the current issues could be to 1) gain inspiration from countries who (also) have well-run primary health care sectors (here Israel has been enhanced as an interesting example that performs well on a number of indicators (OECD 2012, Barua and Jacques 2018, Rotenberg et al. 2022)) and explore the contexts of these sectors, and 2) join forces with other academic disciplines, e.g. researchers from primary care, public administration, organizational theory etc. to shed light on the topic from different angles using different methods. Finally, it is of utmost importance to inform and guide policy makers about which interventions and organizational changes that are deemed successful and how Nordic primary care could best be improved. It can turn out to be a strength that the covid-19 pandemic has forced the health care system and professionals to adapt quickly to the new situation, to collaborate on the treatment of patients between health care sectors, and to develop and provide technological solutions to consult and treat patients at the distance. The next years will tell whether these rapid changes in primary care have accelerated technological progress and led to permanent changes in behaviour that is assumed to enable the realisation of unexploited potential in Nordic primary care. Health economists can contribute to this understanding by investigating whether such changes provide higher quality of care at a more cost-effective level.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Demographic changes and decentralization of health care provision have led to a higher demand for General Practitioners (GP) services in the Nordics. As a result, many countries report that recruiting and retaining GPs are increasingly difficult. Coupled with younger GPs increasingly valuing work/life balance, the Nordic countries are now looking at different policies that can ensure a sustainable GP supply going forward. Relevant policy measures depend on the GP systems in place, which also differs between the countries. We provide an overview of reforms and policies that have been planned or implemented in the last 10 years and use a theoretical framework to discuss their potential effects on recruitment and effort. Our focus is on remuneration schemes, GPs’ working conditions and practice quality as policy levers to incentivize effort and to attract additional GPs. We show that policies that have a positive effect on recruiting GPs can have a negative effect on the effort GPs exert. Since reduced effort might have a negative effect on the services patients receive, the total effects of the policies are uncertain. We further show that the dominating effect is sensitive to preferences and characteristics of the GPs, providing important insights for policy makers who want to increase GP supply.
In Finland, occupational healthcare (OHC) provides alternative access to curative ambulatory primary healthcare for a large proportion of the employed. Providers of occupational and private healthcare can also refer patients to public secondary healthcare, possibly providing better access to specialized medicine. We investigate the determinants of the use of OHC and associations between the use of OHC and other ambulatory service sectors and distributions of ambulatory healthcare. We find that the probability of using OHC is positively associated with the size of the employing organization and is higher for those with higher incomes but does not vary strongly between patients with different health conditions. Those who use OHC visit public health centres less often, but the negative association is not strong: the use of occupational healthcare seems to be associated with an overall higher use of ambulatory services. The results show that ambulatory healthcare is not allocated according to need in Finland. Those with higher incomes are in better health and use more OHC and private healthcare. Published: Online July 2022
A main objective of the Nordic healthcare systems is to deliver timely and equal access to high-quality healthcare to the entire population. Health care providers, such as general practitioners (GPs), may therefore experience pressure to deliver care from both the health authorities and patients. However, if GPs’ gains do not outweigh their costs of providing the demanded care, it may lead to job dissatisfaction and thereby potentially to poorer quality of care. This study contributes to the literature by estimating the association between different sources of experienced work pressure and job dissatisfaction among GPs. We use data from a nation-wide survey of Danish GPs distributed in 2019. The study includes six items covering GPs’ experienced work pressure, which we categorise based on the degree to which they are related to demands from either patients or health authorities. Using a series of ordered logit models with a rich set of explanatory variables, we estimate the association between the pressure measures and GP job dissatisfaction. We find that GPs reporting high or considerable work pressure have an increased likelihood of also reporting job dissatisfaction. However, we find considerable heterogeneity in this relationship across different sources of work pressure as well as across GP, practice, and area characteristics. For example, the relationship between pressure from patients’ demands for consultations and job dissatisfaction is stronger among GPs practicing in areas with an undersupply of GPs. Solo practitioners, who cannot share their administrative burdens with colleagues, experience a stronger association between pressure from the health authorities and job dissatisfaction. Policymakers should consider this heterogeneity when implementing new schemes and organisational structures affecting GPs’ work pressure. Published: Online January 2022.
This thesis consists of four self-contained empirical chapters with topics at the intersection of economics, health and education.In the first chapter, jointly written with N. Skipper, A. Gaulke, S. Sildorf, T. Eriksen and J. Svensson and published in JAMA (2019), we examine the association between type 1 diabetes and standardized test scores among 631,620 children in Danish public schools.We find no difference in standardized reading and mathematics test scores between children with type 1 diabetes and children without diabetes.In the second chapter, jointly written with N. Skipper, A. Gaulke, T. Eriksen and J. Svensson and published in Diabetes Care (2019), we examine the degree of socioeconomic inequality among Danish children with type 1 diabetes.We document large differences in metabolic control of children across maternal education despite Danish universal access to healthcare.We show that 22.5% of the socioeconomic difference can be explained by more frequent blood glucose monitoring among the children with the highly educated mothers.We consider the number of daily glucose measurements as an indicator of treatment adherence and interpret the associations found between the number of daily glucose measurements and HbA1c as capturing the link between treatment adherence and outcomes.In the third chapter, published in Journal of Health Economics (2019), I examine the causal effect of retirement on health and healthcare utilization using two identification strategies on Danish full population data.I show that early retirement leads to decreases in GP visits and hospitalizations of 8-10% in the short run and that the reduction in GP visits is driven by women.Additionally, I show that early retirement has no effect on health per se and that statutory retirement has no effect on health or healthcare utilization.In the fourth chapter, jointly written with J. Laird and T. Nielsen and yet to be published, we investigate the effects of one of the most prevalent childhood shocks: parental divorce.We apply methods previously used by the literature on new compelling data sources.We find small but precisely estimated negative average effects of early family dissolution on children's human capital formation and significant evidence that parental divorce in early childhood leads to higher risk of mental health problems of children in adulthood
Our objective is to study the competition effect of biosimilar entry in centralized tenders for an expensive category or drugs - TNF-inhibitors. We use monthly observations of prices and volumes for all brands and biosimilars in this drug category in Norway, covering the period from Jan. 2006 to Dec. 2016. Descriptive statistics and regression models are used to investigate the impact of biosimilars on the drug price and the effect of the number of brands on the intensity of competition. Both the entry of biosimilars and new branded drugs have increased competition and reduced prices. According to our estimates, an increase in the market share of biosimilars from 10 % to 60 %, will be accompanied with a 50 % reduction in the expected price. Only two years after entry, the first biosimilars in this drug category had gained a market share of 40 % in Norwegian hospitals. Although entry barriers for biosimilars are higher than for generics of chemical substances, significant cost savings are expected from patent expirations of expensive biologics as well. The centralized design of the tenders is an important institutional factor behind the strong competition effect. Published: Online January 2020
Norway is piloting team-based primary care delivery models: Honorarmodellen (HM) and Driftstilskuddsmodellen (DM). In addition to organisational changes, the DM transforms provider payment, which seems to attract specific practices. This, coupled with the small number of DM practices, makes it difficult to produce credible evidence regarding the model and its effects on health system performance. I examine whether matching methods—specifically, coarsened exact matching, propensity score matching, and propensity score weighting—can improve evaluation in this demanding situation. As in previous studies on the small sample performance of matching methods, I find no clear best method. This suggests using propensity score weighting, which does not discard data. In the final section of the article, I offer additional advice to help improve the evaluation in similar situations.
