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Master Thesis The Coordination Reform: Potential for substitution between primary- and specialist health care in Norway. Analysis of the relationship between municipal health care supply and number of hospital admissions for selected diagnosis groups in Norwegian municipalities, 1999-2007. Einar Sponheim Seim Master Thesis Institute of Health and Society Department of Health Management and Health Economics UNIVERSITETET I OSLO 15.05.2010 Acknowledgements I would like to thank my supervisor, Professor Terje P. Hagen at the Department of Health Management and Health Economics for valuable inputs and feedback in the process of writing this thesis. I would also like to thank my fellow students at the institute for constructive discussions during our shared process of analysing and writing. Einar Sponheim Seim Oslo, May 2010 2 Abbreviations and acronyms RHA Regional Health Authorities/Regionale Helseforetak GP General Practitioner ABF Activity based financing DRG Diagnosis-related group GDP Gross domestic product OECD Organisation for Economic Co-operation and Development NIS National Insurance Scheme ICT Information and Communication Technology R&D Research and Development NOK Norwegian kroner SSB Statistics Norway/Statistisk sentralbyrå ICD-10 Tenth revision of the International Classification of Diseases HT Health Trust/Helseforetak (HF) WHO World Health Organization WLS Weighted least squares GPH General practitioner hospital (sykestue) 3 Abstract BACKGROUND: In June 2009, the Norwegian government presented a proposal for one of the most central health reforms in Norway during the last decades, white paper (St.melding) no. 47, The Coordination Reform. The intention is to improve coordination between the primary- and specialist health care sector. More specifically, the strategy is to transfer responsibility from specialist- to municipal health care services in order to improve quality and counteract the growth in health expenditures. To achieve the stated objectives, organisational, legislative and financial means are planned implemented. OBJECTIVE: To analyse the impact of supply of health care in Norwegian municipalities on use of specialist health care services, hereunder number of hospital admissions for specific diagnosis groups that are believed to hold a potential of being treated within municipal health care services to a larger extent. METHOD: The method used is a weighted least square regression incorporating “fixed effects” for health trust and year, analysing how number of hospital admissions for four main diagnosis groups are affected by supply of health care services in 427 Norwegian municipalities between 1999 and 2007. The thesis is based on diagnosis data that also form the basis for a separate thesis by Alejandra Palacio Perez, performing similar analyses with other relevant diagnosis groups. RESULTS: We find statistically significant and rather strong positive effects of number of municipal physicians and negative effects for general practitioner hospitals (sykestuer) on number of hospital admissions. In addition, we find negative effects of coverage of institutions for elderly. The results indicate that the number of hospital admissions increase with a higher number of man years of physicians. This finding is contrary to one of the means suggested in the white paper of increasing the number of GPs, hereby decreasing the pressure on specialist health care. Further, we find that municipalities that are covered by general practitioner hospitals have fewer admissions to somatic hospitals. Our analyses also indicate that high coverage of institutions within municipalities, results in reduced number of hospital admissions for elderly. 4 Table of contents Acknowledgements......................................................................................................................... 2 Abbreviations and acronyms ........................................................................................................ 3 Abstract ........................................................................................................................................... 4 Table of contents ............................................................................................................................ 5 List of figures .................................................................................................................................. 7 List of tables .................................................................................................................................... 8 1. INTRODUCTION ...................................................................................................................... 9 1.1 Aims and objectives of the study ........................................................................................... 9 1.2 Structure and organisation of Norwegian health care .......................................................... 10 1.3 Policies ................................................................................................................................. 12 1.4 Primary- and specialist health care services ........................................................................ 15 1.5 Financing of health care services ......................................................................................... 18 2. THE COORDINATION REFORM ....................................................................................... 22 2.1 Background for the reform ................................................................................................... 22 2.2 Strategy ................................................................................................................................ 24 2.2.1 Financial incentives....................................................................................................... 25 2.2.2 Increased municipal responsibility ................................................................................ 26 2.2.3 Increased number of General Practitioners ................................................................... 26 2.3 A potential for substitution? ................................................................................................. 27 2.4 Experiences from Denmark ................................................................................................. 28 3. THEORETICAL FOUNDATION ......................................................................................... 29 3.1 Need, demand and consumption .......................................................................................... 29 3.2 Distribution of responsibility ............................................................................................... 31 4. DATA AND METHODS ........................................................................................................ 34 4.1 Study design ......................................................................................................................... 34 4.2 Data sources and limitations ................................................................................................ 35 4.3 Statistical analysis tool ......................................................................................................... 35 4.4 Weighted least squares (WLS) regression ........................................................................... 36 4.5 Empirical model ................................................................................................................... 37 4.6 Fixed effects ......................................................................................................................... 37 5 4.7 Statistical assumptions ......................................................................................................... 38 4.8 Variables .............................................................................................................................. 38 4.8.1 Main diagnosis groups (dependent variables) ............................................................... 38 4.8.2 Variables describing supply .......................................................................................... 42 4.8.3 Variables describing need ............................................................................................. 43 4.8.4 Variables concerning the effect of local medical centres ............................................. 44 4.9 Descriptive statistics ............................................................................................................ 44 4.9.1 Descriptive statistics, total population .......................................................................... 45 4.9.2 Descriptive statistics, population 80 and over .............................................................. 46 5. RESULTS ................................................................................................................................. 48 5.1 Diabetes mellitus (E10-E14) ................................................................................................ 48 5.1.1 Diabetes mellitus, total population................................................................................ 48 5.1.2 Diabetes mellitus, population 80 and over .................................................................... 51 5.2 Heart diseases (I00-I99) ....................................................................................................... 53 5.2.1 Heart diseases, total population ...................................................................................
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