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Lindaas NA, Anthun KS, Kittelsen SAC, Magnussen J. Economies of scope in the Norwegian public hospital sector. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024:10.1007/s10198-024-01704-z. [PMID: 39023659 DOI: 10.1007/s10198-024-01704-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
This study investigates the potential economies of scope in the Norwegian public hospital sector after a major structural and organizational reform. Economies of scope refers to potential cost savings occurring from the scope of production rather than the scale. We use a data driven approach to distinguish between relatively specialized and differentiated hospitals. Using registry data spanning the period 2013-2019, we use non-parametric data envelopment analysis with bootstrapping procedures to investigate the potential presence of economies of scope. This is done separately for three different dimensions of which hospital production can be either specialized or differentiated. The findings suggest that economies of scope are present in the Norwegian hospital sector, meaning that there are cost savings related to the optimal differentiation of the activity. It is difficult to conclude on how these findings relate to the reform.
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Affiliation(s)
- Nils Arne Lindaas
- Department of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, Trondheim, 7491, Norway.
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, Trondheim, 7491, Norway
- Department of Health Research, SINTEF Digital, P.O. Box 4760, Torgarden, Trondheim, 7465, Norway
| | - Sverre A C Kittelsen
- Ragnar Frisch Centre for Economic Research, Gaustadalléen 21, Oslo, 0349, Norway
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 1089, Blindern, Oslo, 0317, Norway
| | - Jon Magnussen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, P.O. Box 8905, Trondheim, 7491, Norway
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Ge G, Iversen T, Kaarbøe O, Snilsberg Ø. Impacts of Norway's extended free choice reform on waiting times and hospital visits. HEALTH ECONOMICS 2024; 33:779-803. [PMID: 38200667 DOI: 10.1002/hec.4801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
Norway's extended free choice (EFC) reform extends the patient's choice of publicly funded hospitals for treatment to authorized private institutions (EFC providers). We study the effects of the reform on waiting times, number of visits, and patients' Charlson Comorbidity Index scores in public hospitals. We use a difference-in-differences model to compare changes over time for public hospitals with and without EFC providers in the catchment area. Focusing on five prevalent somatic services, we find that the EFC reform did not exert pressure on public hospitals to stimulate shorter waiting times and more visits. Moreover, we do not find that the sum of public and private visits increased. When we compare patient comorbidity between public hospitals and EFC providers, we find that for non-invasive diagnostic services, patient comorbidity is lower in EFC providers. For surgical services, we detect no difference in patient comorbidities between public and EFC providers.
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Affiliation(s)
- Ge Ge
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Tor Iversen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Oddvar Kaarbøe
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Economics, University of Bergen, Bergen, Norway
| | - Øyvind Snilsberg
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Danielsen E, Mjåset C, Ingebrigtsen T, Gulati S, Grotle M, Rudolfsen JH, Nygaard ØP, Solberg TK. A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals. Sci Rep 2022; 12:12856. [PMID: 35896806 PMCID: PMC9329342 DOI: 10.1038/s41598-022-17194-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the differences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P < 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P < 0.001). A larger proportion of patients in private hospitals had high education (≥ 4 years of college or university) (42.9% vs 35.6%, P < 0.001). Patients in public hospitals had worse disease-specific health problems than those in private hospitals: unadjusted NDI mean difference was 5.2 (95% CI 4.4 – 6.0; P < 0.001) and adjusted NDI mean difference was 3.4 (95% CI 2.5 – 4.2; P < 0.001), and they also had longer duration of symptoms (P < 0.001). Duration of surgery (mean difference 29 minutes, 95% CI 27.1 – 30.7; P < 0.001) and length of hospital stay (mean difference 2 days, 95% CI 2.3 – 2.4; P < 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efficiently. Our findings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status.
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Affiliation(s)
- Elisabet Danielsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
| | | | - Tor Ingebrigtsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of North Norway, Tromsø, Norway.,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Sasha Gulati
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Margreth Grotle
- Centre for Intelligent Musculoskeletal Health, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.,Communication Unit for Musculoskeletal Disorders (FORMI), Oslo University Hospital, Oslo, Norway
| | - Jan Håkon Rudolfsen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Øystein P Nygaard
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Tore K Solberg
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of North Norway, Tromsø, Norway
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Lindén TS, Ervik R. Health services in Nordic welfare states: Introducing a new category of providers through the Norwegian free treatment choice reform. NORDIC STUDIES ON ALCOHOL AND DRUGS 2022; 39:487-502. [PMID: 36284746 PMCID: PMC9549221 DOI: 10.1177/14550725221108790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Aim: We contribute to the literature on private provision of health care in Nordic countries by studying developments following the 2015 Norwegian free treatment choice reform. The reform introduced new providers of publicly financed health care. These new private for-profit or not-for-profit providers are licensed by Helfo (the Norwegian Health Economics Administration) to offer pre-defined services at pre-defined prices. They treat patients referred to specialist health care given that patients choose these providers. We focus on multidisciplinary specialist substance treatment and mental health care, areas constituting 78% of reform costs in 2019. Methods and data: We discuss three sets of questions with statistics, documents, and interview data: What developments and consequences of new providers did key actors expect? What developments of Helfo-licensed providers do we see and why? How have Helfo-licensed providers influenced collaboration between public and non-public providers and recruitment? Results: Contrary to expectations, we found that most Helfo-licensed providers have not previously collaborated with public providers through tender agreements. This complicates collaboration. So far, the establishment of new providers has not undermined public providers in terms of recruitment. Conclusion: Public providers with Helfo-licensed providers in their area still experience some pressure on recruitment and express concerns for future negative reform consequences. The introduction of new private providers may influence the level of market-orientation in the Norwegian welfare state.
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Kort NP, Zagra L, Barrena EG, Tandogan RN, Thaler M, Berstock JR, Karachalios T. Resuming hip and knee arthroplasty after COVID-19: ethical implications for wellbeing, safety and the economy. Hip Int 2020; 30:492-499. [PMID: 32635761 PMCID: PMC7345437 DOI: 10.1177/1120700020941232] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Reinstating elective hip and knee arthroplasty services presents significant challenges. We need to be honest about the scale of the obstacles ahead and realise that the health challenges and economic consequences of the COVID-19 pandemic are potentially devastating.We must also prepare to make difficult ethical decisions about restarting elective hip and knee arthroplasty. These decisions should be based on the existing evidence-base, reliable data, the recommendations of experts, and regional circumstances.
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Affiliation(s)
| | - Luigi Zagra
- IRCCS Istituto Ortopedico
Galeazzi, Hip Department, Milan, Italy
| | - Enrique Gomez Barrena
- Department of Orthopaedic Surgery
and Traumatology, Hospital La Paz, Autonomous University of Madrid, Madrid,
Spain
| | | | - Martin Thaler
- Department of Orthopaedic Surgery,
Medical University of Innsbruck, Innsbruck, Austria
| | - James R Berstock
- Department of Orthopaedics, Royal
United Hospital Bath, Bath, UK
| | - Theofilos Karachalios
- Orthopaedic Department, University
General Hospital of Larissa, School of Health Sciences, Faculty of Medicine,
University of Thessalia, Thessalia, Greece,Theofilos Karachalios, Orthopaedic
Department, University General Hospital of Larissa, School of Health
Sciences, Faculty of Medicine, Biopolis Mezourlo Region, Larissa,
41110, Greece.
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Holom GH, Alexandersen N, Goldhaber-Fiebert JD, Hagen TP. Which patients receive surgery in for-profit and non-profit hospitals in a universal health system? An explorative register-based study in Norway. BMJ Open 2018; 8:e019780. [PMID: 29886441 PMCID: PMC6009459 DOI: 10.1136/bmjopen-2017-019780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To compare the socioeconomic status (SES) and case-mix among day surgical patients treated at private for-profit hospitals (PFPs) and non-profit hospitals (NPs) in Norway, and to explore whether the use of PFPs in a universal health system has compromised the principle of equal access regardless of SES. DESIGN A retrospective, exploratory study comparing hospital types using the Norwegian Patient Register linked with socioeconomic data from Statistics Norway by using Norwegian citizens' personal identification numbers. SETTING The Norwegian healthcare system. POPULATION All publicly financed patients in five Norwegian metropolitan areas having day surgery for meniscus (34 100 patients), carpal tunnel syndrome (15 010), benign breast hypertrophy (6297) or hallux valgus (2135) from 2009 to 2014. PRIMARY OUTCOME MEASURE Having surgery at a PFP or NP. RESULTS Across four unique procedures, the adjusted odds ratios (aORs) for using PFPs were generally lower for the lowest educational level (0.77-0.87) and the lowest income level (0.68-0.89), though aORs were not always significant. Likewise, comorbidity and previous hospitalisation had lower aORs (0.62-0.95; 0.44-0.97, respectively) for having surgery at PFPs across procedures, though again aORs were not always significant. No clear patterns emerged with respect to age, gender or higher levels of income and education. CONCLUSIONS The evidence from our study of four procedures suggests that equal access to PFPs compared with NPs for those patients at the lowest education and income levels may be compromised, though further investigations are needed to generalise these findings across more procedures and probe causal mechanisms and appropriate policy remedies. The finding that comorbidity and previous hospitalisation had lower odds of treatment at PFPs indicates that NPs play an essential role for more complex patients, but raises questions about patient preference and cream skimming.
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Affiliation(s)
- Geir Hiller Holom
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, Oslo, Norway
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Nina Alexandersen
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Terje P Hagen
- Department of Health Economics and Health Management, Institute of Health and Society, University of Oslo, Oslo, Norway
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Holom GH, Hagen TP. Quality differences between private for-profit, private non-profit and public hospitals in Norway: a retrospective national register-based study of acute readmission rates following total hip and knee arthroplasties. BMJ Open 2017; 7:e015771. [PMID: 28821517 PMCID: PMC5724080 DOI: 10.1136/bmjopen-2016-015771] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 05/26/2017] [Accepted: 06/20/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To compare the quality of care-using unplanned acute hospital readmissions as a quality measure-among patients treated at private for-profit hospitals (PFPs), private non-profit hospitals (PNPs) and public hospitals (PUBs) in Norway. DESIGN A retrospective comparative study using the Norwegian Patient Register. Readmissions were evaluated by logistic regressions both using adjustment for various patient-level and other covariates, and a two-stage model using distance as an instrumental variable. SETTING The Norwegian healthcare system. POPULATION All publicly financed patients having primary total hip (37 897 patients) or primary total knee arthroplasty (25 802 patients) at one of the three hospital types from 2009 to 2014. PRIMARY OUTCOME MEASURE 30-day unplanned acute hospital readmission rate. RESULTS We found highest readmission rates among PUBs and lowest among PFPs, for both procedures. However, the patients were on average more than 2 years younger at PFPs. PFPs also treated the least severe patients, while PUBs treated the most severe. Using adjustment for various patient-level and other covariates, compared to PUBs, both PFPs and PNPs had lower odds of readmission following both procedures. However, using the instrumental variable method, the only significant difference found was a lower odds of readmission at PNPs among hip patients when compared with PUBs. No patients in our data set were readmitted to PFPs, those originally treated at PFPs were readmitted to either PNPs or PUBs, and PUBs received most of the readmitted patients across hospital types. CONCLUSIONS Quality differences between hospital types were small; however, PNPs had significantly lower readmission rates compared with PUBs among patients having total hip arthroplasty. PUBs received the larger part of the readmitted patients across hospital types and thus play an essential role in the care of more complex patients and for readmissions, regardless of any quality differences.
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Affiliation(s)
- Geir Hiller Holom
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Terje P Hagen
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
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