Remuneration and organization in general practice: Effects on recruitment, practice profile, and task division between care levels

Some key findings from discrete choice experiments in sub-project A: Very few young doctors want to work in the smallest district municipalities. The study shows that further wage increases (from current levels) are likely to have limited effects in terms of attracting more young doctors to rural areas in Norway. Improvements in the ability to control working hours and the opportunity for professional development in small rural municipalities will likely have a greater effect. Only 20% prefer a full activity-based payment system similar to the existing system for GPs in Norway. GP preferences for income are reference-dependent, i.e. they have a strong aversion to wage decrease, while increases from their current wages are valued less. Accordingly, wage increasing incentives probably have limited effect as a means of influencing physician behavior. Academic and professional autonomy are highly valued. Another key finding is that the proportion who prefer today's standard mode of operation of private practice has declined from 52% in 2009 to 36% in 2012. Some key findings from laboratory experiment in sub-project B: Quality improvements in markets for medical are key objectives in any health reform. An important question is whether disclosing physicians' performance can contribute to achieving these objectives. Due to the asymmetric information inherent in medical markets, one may argue that changes in the information structure are likely to influence the environment in which health care providers operate. In a laboratory experiment we analyze the effect of disclosing performance information by making medical students? treatment decisions known to their peers. We find that making performance transparent has a positive impact on patients' health. The magnitude of the effect is small. Some key findings of effects of improved capacity in primary care: We study gatekeeping physicians? referrals of patients to specialty care. We derive theoretical resultswhen competition in the physician market intensifies. First, due to competitive pressure, physicians referpatients to specialty care more often. Second, physicians earn more by treating patients themselves, sorefer patients to specialty care less often. We assess empirically the overall effect of competition with datafrom a 2008 Norwegian survey, National Health Insurance Administration, and Statistics Norway.From the data we construct three measures of competition: the number of open primary physician prac-tices with and without population adjustment, and the Herfindahl Hirschman index. The empirical resultssuggest that competition has negligible or small positive effects on referrals overall. Our results do notsupport the policy claim that increasing the number of primary care physicians reduces secondary care. In a supplementary study of gatekeeping and supply of specialist health services we examine the implications of a change in the payment scheme for radiology providers in Norway that was implemented in 2008. The change implies reduced fee-for-service and increased fixed budget for a contracted volume of services. A consequence of the change is that private providers have less incentive to conduct examinations beyond the contracted volume. Different from the situation observed before the change in 2008, the volume is no longer determined by the demand side, and a rationing of the supply occurs. We employ data on radiological examinations initiated by GPs? referrals. We apply monthly data at the physician-practice level for 2007-2010. The data set is unique because it includes information about all GPs in the Norwegian patient-list system. The results indicate that private providers conducted fewer examinations in 2008-2010 compared with previous periods and that public hospitals did either the same volume or more. We find that GPs who operate in a more competitive environment experienced a greater reduction in magnetic resonance imaging, both performed by private providers and in total for their patients. We argue that this result supports a hypothesis that patients with lower expected benefits are rationed. Hence, rationing from the supply side might supplement GP gatekeeping. Patients with chronic diseases benefit from appropriate continuity of care and generally visit their GPs more often than the average patient. Our aim was to study disenrollment patterns among patients with chronic diseases in Norway, because such patterns could indicate otherwise unobserved GP quality. For instance, higher quality GPs could have both a greater share of patients with chronic diseases and lower disenrollment rates. Data on 384,947 chronic patients and 3,974 GPs for the years 2009-2011 were obtained from national registers, including patient and GP characteristics, disenrollment data, and patient list composition. The GPs? proportion of patients with a given chronic disease varied more than expected when the allocation was purely random. Patients t

The coordination reform proposal from the Norwegian government was rejected by the Storting (parliament) because of missing evidence of a connection between goals and measures. Policy measures needed to recruit the large number of general practitioners ( GPs) to the rural areas was absent and there was no evidence of how an increase in the number of GPs would simultaneously stop the cost escalation and improve the quality of health care. Hence, research that contributes to evidence based health care refor m is much needed in Norway. We offer this research and approach the research questions with a wide selection of methods from theory development, survey design and discrete choice experiments, econometric panel data analyses of national register databases and controlled laboratory experiments. There are two sub-projects. The first subproject studies stated preferences for key characteristics of working as a GP. In addition to remuneration systems, a wide range of non-pecuniary job characteristics; e.g. pr actice team size and structure, professional development, patient list size, on-call arrangements, task division with specialist care are included. The second sub-project studies how capacities in primary care and specialist care influence access to GPs, services provided by GPs, and prescriptions and referrals from GPs to specialist care. We ask to what extent specialist health care is a substitute or a complement to primary health care. Selections of national and international partners are carefully don e. This is the first quantitative study of general practice in Norway that involves both clinicians and economists. To further strengthen the research team, we have included world class researchers in the economics of physician behavior and experimental e conomics. We believe that the project has a potential of achieving research results that are both innovative and crucial for policy decisions.