Modernizing the GP scheme: towards sustainable health policy

GPs plays a crucial role in the overall healthcare system. It is at the GP level that the population's primary healthcare needs are met, and the GP should contribute to ensuring continuity in this regard. The increasing challenges of recruiting and retaining GPs are therefore concerning. To meet the growing demand from patients, decision-makers need to understand how to increase the supply of GP services with limited resources. We have analyzed how different reimbursement systems for GPs can achieve an increased service supply and how decision-makers can achieve the desired service provision without solely relying on economic incentives. One example is the use of information campaigns targeted at either GPs or patient groups. Another example is the implementation of training programs. To provide a comprehensive assessment of GPs' and patients' responses to various policy interventions, we employ theoretical models, observational data, and experimental methods. Our research has shown that incentives aimed at increasing service provision among existing GPs can lead some to leave the profession while discouraging others from entering it. Furthermore, we have uncovered unintended consequences of payment systems that include tariffs, particularly concerning billing practices and patient selection, and have measured the effects of measures aimed at mitigating these issues. Our research highlights the value of continuity in the doctor-patient relationship. However, it also suggests that an indicator based on each patient's contacts with their GP may overestimate the importance of continuity as a characteristic of general practice. An alternative, service-based measure of continuity could be suitable as a quality measurement in primary healthcare. The GP also plays a critical role as a gatekeeper through their decisions regarding patient referrals. However, many referrals are declined, and there is significant variation in the proportion of declined referrals across hospitals, particularly within certain medical specialties. In our study, we investigate the characteristics of children and adolescents whose referrals to Child and Adolescent Mental Health Services (BUP) are rejected. Our analysis reveals that, on average, 22% of referrals to BUP are declined, with the proportion of declined referrals ranging from 3% to 31%. The analyses indicate that this variation can be attributed to factors beyond patient and referring GP characteristics. We find a significant socioeconomic gradient in the proportion of declined referrals, with the likelihood of referral rejection being nearly 10% higher for patients whose parents' highest educational attainment is primary or secondary education. Many patients who have their initial referrals declined are re-referred within a short period, and 80% of these re-referred patients are granted access to healthcare services. We examine how socioeconomic status, measured by education and income, affects waiting times for somatic hospital treatment while controlling for patients' health status, the type of treatment they are awaiting, and factors that influence the healthcare services patients have access to (including GPs). We measure patients' socioeconomic status at an individual level. Our data enable us to decompose the socioeconomic gradient in terms of whether patients are directly referred to day or inpatient treatment or if they are first referred to outpatient treatment before subsequently receiving day or inpatient treatment. Our hypothesis is that GPs' referrals play a role in determining whether hospitals have enough information to directly allocate patients to day or inpatient treatment. We find small effects of socioeconomic status on patients' waiting times relative to what is commonly reported in the research literature. Furthermore, we find that the likelihood of direct referral (i.e., without first visiting an outpatient clinic) primarily explains the socioeconomic gradient. Information campaigns can be used to influence behavior. We examine whether audit and feedback can be used to change GPs' clinical practices, specifically focusing on whether GPs' utilization of lengthy patient consultations is influenced when they are informed about their high consumption of such consultations. We measure the effect using data from a field experiment conducted by HELFO in 2019. In the field experiment, GPs with high utilization of lengthy consultations were divided into intervention and control groups. The intervention group received an email (sent by HELFO) containing information about the amount of reimbursement HELFO provided for lengthy consultations in 2018, along with the notification that they had a high utilization of lengthy consultations. Our results indicate that the intervention group reduced their utilization of lengthy consultations by approximately 2-5 percentage points, and the effect persisted throughout the entire period for which we have data (14 months).

* Vi har etablert et longitudinelt datasett med detaljert informasjon på individnivå fra både primær- og sekundærhelsetjenesten, samt individuell informasjon om sosioøkonomisk status, etnisitet, familierelasjoner og data om bruk av legemidler. * Vi har utviklet samarbeid på tvers av disipliner og institusjoner (både i Norge og internasjonalt) * Vi har hatt brukerinvolvering, blant annet gjennom forberedte kommentarer på det nasjonale helseøkonomikonferansen og gjennom innspill til fellessesjoner på den europeiske helseøkonomikonferansen vi var med å arrangere i Oslo i 2022 (EUHEA 2022). Vi har også hatt brukerinvolvering i de tre felteksperimentene vi har gjennomført. Diabetesforbundet har vært med som partner i ett av våre felteksperiment. HELFO kontroll har vært med som partner i to av våre felteksperiment. * Vår stipendiat leverer sin avhandling (om fastlegeordningen) i juni 2023 * Per nå har vi ikke utviklet en EU-søknad basert i prosjektgruppen, men dette er noe vi vil vurdere i året som kommer.

We are studying coordination of health care by General Practitioners (GPs) by analysing their decisions regarding continuity of care, treatment, and referral. The project is comparative as data from Denmark and Norway will be combined in several analyses. The project is directly related to structural, organizational and financial aspects that i) hinder and foster coordinated and integrated health services, and ii) that contribute to a sustainable health sector with greater equality among users of equal need. Furthermore, one main point is to emphasise how the regular general practitioner scheme affects the prioritised themes. The project involves cooperation between researchers from different disciplines (economics, medicine and public health) and different institutions (University of Oslo, Uni Research Rokkan centre, The University of Southern Denmark, NTNU, and cooperation with University of York, the leading centre in Europe for research in health economics). An important aim is to establish a unique longitudinal data set with detailed patient level information from both primary and secondary care, as well as individual information on socioeconomic status, ethnicity and family relations. We will use different panel data and multilevel estimators combined with innovative empirical strategies to analyse the effects on the GPs allocation of health care. The project is organized in four work packages: 1) Continuity in GP-patient relationship and quality of care 2) Remuneration (Payments) 3) Equality 4) Evaluating primary care quality for patients with type 2 diabetes (T2D)