In several European countries, including Norway, polices to increase patient choice of hospital provider have remained high on the political agenda. The main reason behind the interest in hospital choice reforms in Norway has been the belief that increasing choice can remedy the persistent problem of long waiting times for elective hospital care. Prior to the 2013 General Election, the Conservative Party campaigned in favour of a new choice reform: "the treatment choice reform". This article describes the background and process leading up to introduction of the reform in the autumn of 2015. It also provides a description of the content and discusses possible implications of the reform for patients, providers and government bodies. In sum, the reform contains elements of both continuity and change. The main novelty of the reform lies in the increased role of private for-profit healthcare providers.
Waiting times for elective care have been considered a serious problem in many health care systems. A topic of particular concern has been how administrative boundaries act as barriers to efficient patient flows. In Norway, a policy combining patient's choice of hospital and removal of restriction on referrals was introduced in 2001, thereby creating a nationwide competitive referral system for elective hospital treatment. The article aims to analyse if patient choice and an increased opportunity for geographical mobility has reduced waiting times for individual elective patients.
A survey conducted among Norwegian somatic patients in 2004 gave information about whether the choice of hospital was made by the individual patient or by others. Survey data was then merged with administrative data on which hospital that actually performed the treatment. The administrative data also gave individual waiting time for hospital admission. Demographics, socio-economic position, and medical need were controlled for to determine the effect of choice and mobility upon waiting time. Several statistical models, including one with instrument variables for choice and mobility, were run.
Patients who had neither chosen hospital individually nor bypassed the local hospital for other reasons faced the longest waiting times. Next were patients who individually had chosen the local hospital, followed by patients who had not made an individual choice, but had bypassed the local hospital for other reasons. Patients who had made a choice to bypass the local hospitals waited on average 11 weeks less than the first group.
The analysis indicates that a policy combining increased opportunity for hospital choice with the removal of rules restricting referrals can reduce waiting times for individual elective patients. Results were robust over different model specifications.
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During the 1980s and 1990s, increased waiting times for elective surgery was perceived to be a major accessibility problem in many countries. In an attempt to improve access, hospital choice reforms were introduced in a number of countries. In Norway, a nationwide reform to improve access came into effect in 2001. At the same time, renewed support was expressed for the long-standing political aim of ensuring equal access to healthcare services for all citizens regardless of their social position. The current aim is to analyse the relationship of the hospital choice reform and the goal of equitable access to hospital services.
A survey conducted among Norwegian patients in 2004 provided information about whether a choice of hospital had been made. Information from the survey was merged with administrative data from the hospital that performed the treatment. The survey provided data on patients' socioeconomic position. Demographics, medical need, and prior use of healthcare services were controlled for to determine the effect of socioeconomic position on hospital choice.
The patient's socioeconomic position, measured by education, was found to be significantly associated with hospital choice. The relationship resembled that of a social gradient. Patients with a primary education were less likely to have made a choice, followed by those with secondary education or a lower university degree. Patients with higher university education were most likely to have chosen.
Hospital selection is a demanding task for many patients. Policymakers should therefore focus on crafting and implementing tools necessary for supporting uptake of choice in disadvantaged groups.
Health systems worldwide struggle to meet increasing demands for health care, and Norway is no exception. This paper discusses the new, comprehensive framework for priority setting recently laid out by the third Norwegian Committee on Priority Setting in the Health Sector. The framework posits that priority setting should pursue the goal of "the greatest number of healthy life years for all, fairly distributed" and centres on three criteria: 1) The health-benefit criterion: The priority of an intervention increases with the expected health benefit (and other relevant welfare benefits) from the intervention; 2) The resource criterion: The priority of an intervention increases, the less resources it requires; and 3) The health-loss criterion: The priority of an intervention increases with the expected lifetime health loss of the beneficiary in the absence of such an intervention. Cost-effectiveness plays a central role in this framework, but only alongside the health-loss criterion which incorporates a special concern for the worse off and promotes fairness. In line with this, cost-effectiveness thresholds are differentiated according to health loss. Concrete implementation tools and open processes with user participation complement the three criteria. Informed by the proposal, the Ministry of Health and Care Services is preparing a report to the Parliament, with the aim of reaching political consensus on a new priority-setting framework for Norway.
Norways five million inhabitants are spread over nearly four hundred thousand square kilometres, making it one of the most sparsely populated countries in Europe. It has enjoyed several decades of high growth, following the start of oil production in early 1970s, and is now one of the richest countries per head in the world. Overall, Norways population enjoys good health status; life expectancy of 81.53 years is above the EU average of 80.14, and the gap between overall life expectancy and healthy life years is around half the of EU average. The health care system is semi decentralized. The responsibility for specialist care lies with the state (administered by four Regional Health Authorities) and the municipalities are responsible for primary care. Although health care expenditure is only 9.4% of Norways GDP (placing it on the 16th place in the WHO European region), given Norways very high value of GDP per capita, its health expenditure per head is higher than in most countries. Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments.The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. However, long waiting times for elective care continue to be a problem and are cause of dissatisfaction among the patients. The focus of health care reforms has seen shifts over the past four decades. During the 1970s the focus was on equality and increasing geographical access to health care services; during the 1980s reforms aimed at achieving cost containment and decentralizing health care services; during the 1990s the focus was on efficiency. Since the beginning of the millennium the emphasis has been given to structural changes in the delivery and organization of health care and to policies intended to empower patients and users. The past few years have seen efforts to improve coordination between health care providers, as well as an increased attention towards quality of care and patient safety issues. Overall, comparing mortality rates amenable to medical intervention suggests that Norway is among the better performing European countries. Despite having one of the highest densities of physicians in Europe, though, Norway still struggles to ensure geographical and social equity in access to health care.
The right to choose a hospital was granted to Norwegian elective patients through the Patients' Rights Act of 2001. The Act assumes that hospital choice will be executed by patients and general practitioners (GPs) at the point of referral. This study examined the probability of referring patients away from the nearest hospitals for three common elective diagnoses: hip replacement, knee surgery, and back pain treatment.
Data describing referral rates and individual characteristics with the GP were collected by a self-administered questionnaire to Norwegian GPs in 2004 and 2006. These were combined with data on interactions between the GP and the local hospital from a database describing the hospital's internal organisation, variables describing needs (demand) at local government level from Statistics Norway, variables describing waiting times from the Norwegian Patient Register, and variables describing travelling distances to the nearest hospital and hospital characteristics. The probability of referring patients away from the nearest hospital was analysed using a cross-section regression model with fixed effects for region, years, and hospital type.
GPs were on average more reluctant to send patients away for hip surgery and back pain than they were for knee surgery. Formal coordinative mechanisms between the hospitals and the GPs - meeting places and arenas for information exchange - significantly reduced the likelihood of referring patients away from the local hospital. Long waiting times and long distances to the local hospital also increased the probability of abandoning the local hospital.
Hospital managers could attract elective patients by developing arenas for communication and collaboration with local GPs.