Incentives, Efficiency and Quality of Care in Long Term Care For The Elderly

This project examines how financial incentives and the organization of long-term care for the elderly affect their mortality, health and quality of life. We do this by connecting patient data from various registers, including information on institutional and home-based services from the Nursing Home Agency in Oslo, so that service providers such as the Nursing Home Agency gain greater insight into the effects of financial incentives and the organization of care services. Standard statistical methods are used to identify causal mechanisms. Qualitative studies of the patient's experience complement the statistical analyses. The project consists of three parts. A study of selection mechanisms in the provision of long-term care services looks at how economic incentives interact with health and socio-economic variables. Key questions are whether and how (i) care services are offered solely on the basis of need, (ii) city districts as service providers are influenced by economic incentives, (iii) care service profiles affect longevity and health and (iv) user fees affect the use of care services across groups. We find, among other things, that economic incentives, such as the size of user fees, have no significance for the allocation of nursing home places in Oslo. In other words, these are allocated on the basis of need. On the other hand, we find signs of strategic adaptation for users of various care services, as the income of the elderly decreases after they have moved to a nursing home. This result applies mostly to residents with children. We do not find similar results for elderly people who move to a care home or a care home with round-the-clock staffing. The second main issue relates to the organization of care provision, more precisely whether it matters for staff and users whether nursing homes are private or public. Based on individual data on wages and sickness absence in nursing homes with publicly funded places in 2015-2020, we find, among other things, that there are large wage differences between private and municipal nursing homes in Oslo, also when we take into account the composition of employees. When it comes to sickness absence, there are no clear differences between them. It is difficult to measure actual quality differences for nursing homes, but based on data, we find that commercial nursing homes have a slightly higher mortality rate and a slightly lower rate of acute hospitalizations within a year of admission, compared to public nursing homes. These conflicting trends in mortality and hospitalizations may be due to competing risks, as deceased patients obviously cannot be hospitalized. However, there was no appreciable effect on the combined risk of hospitalization and mortality. The third issue is the role of GPs in elderly care, with a focus on economic incentives. GPs' earnings depend on list length and services. For a given number of services, the GP will profit from a long patient list, i.e. it will be profitable to have many healthy patients. Older patients have, on average, a greater need for medical services. However, we find that the proportion receiving care services on the GPs' lists in Oslo is roughly the same for GPs with long and short lists. Economic incentives thus have little significance for the GP's list composition. A final issue is how the introduction of care technology affects the use of nursing home services, labor in the care sector and municipal costs. We have looked at Lindås municipality and Lister municipalities, which have been pioneering municipalities in this regard. Our results show no evidence that the program had an effect on long term care expenditures, mortality, and the utilization of specialized and municipal health services. However, there is little data in this field, and it will be interesting to study this in more detail when a larger data material is available.

Vi står ovenfor en demografisk endring, som gir en lavere andel sysselsatte i befolkningen i årene framover. Den økte andelen eldre vil legge et stort press på offentlige budsjetter. Det er derfor viktig med en effektiv bruk av ressursene, samtidig som at det er ønskelig å opprettholde kvaliteten på tjenestene, og at tjenestene skal gis etter behov uavhengig av sosioøkonomisk status. Våre resultater belyser hvordan organisering av pleie- og omsorgstjenestene, både når det gjelder eierskap og bruk av økonomiske virkemidler, har betydning for effektivitet, kvalitet og fordeling. Hvis organiseringen gir uønskede effekter, vil det være viktig å korrigere disse før den største bølgen av eldre omsorgstrengende kommer. Våre resultater er til dels overraskende, men også positive. Selv om økonomiske insentiver er innført, gis tjenestene fortsatt etter behov og det er ingen seleksjon av pasienter etter sosioøkonomisk status. De økonomiske virkemidlene ser ikke ut til å påvirke fastlegenes lister, slik at fastlegene heller ikke foretar en seleksjon av pasienter. Selv om det er forskjeller for mellom private og offentlige sykehjem for de ansatte, er det ingen klar effekt for brukernes helse og funksjonsevne. Disse resultatene er formidlet og vil bli videreformidlet til Sykehjemsetaten i Oslo som er den viktigste brukeren og samarbeidspartneren i prosjektet. De er også formidlet til andre brukere gjennom fordrag og populærvitenskaåelige publikasjoner. Resultatene viser at i Norge fungerer organiseringen og virkemiddelbruken i hovedsak godt for brukere og ansatte i pleie- og omsorgssektoren, og de er ikke behov for store endringer i organisering, selv om det trengs en stor oppskalering de nærmeste årene for å møte den økte etterspørselen. Prosjektet har vært lærerikt for forskerne som bygger videre på dette i sin forskning. Flere av artiklene er publisert i gode internasjonale tidsskrift, og prosjektet vil dermed også få betydning for den internasjonale forskningen på feltet.

The project examines how incentives in the organisation of long term care for the elderly affect their mortality, health and quality of life. We will do this by merging individual patient data from various registers, including information on institutional and home based services from Oslo Nursing Home Agency (ONHA), allowing care providers like ONHA to better understand the effect of economic incentives. State of the art statistical methods will be used to identify causal mechanisms. Extraordinarily detailed data, combined with the expertise of care providers, pave the ground for high quality internationally publishable research. Qualitative studies of patient experience complement the statistics. A study of selection mechanisms in the provision of long term care will examine how economic incentives interact with health and socio-economic variables. Key questions are whether and how (i) care services are provided solely on the basis of needs, (ii) municipal districts as care providers are affected by economic incentives, (iii) care service profiles affect longevity and health and (iv) user fees affect use of care across groups. A study of nursing home privatization will build on recent transfers of operation to private companies, using longitudinal data of care provision, patients' characteristics and workforce qualifications for Oslo. Identification of quality differences needs a credible research strategy. The assignment system in Oslo enables us to compare outcomes of patients with identical preferences, (in practice) randomly allocated across institutions. Qualitative studies complement the statistical studies to achieve verification and interpretation of results. We will also examine effects of privatization on the workforce as well as productivity. The role of the regular general practitioners in elderly care will be examined, focusing on the extent to which economic incentives affect care services allocation across space and socioeconomic variable.