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Privatizing the health-care sector: Expansion of voluntary, private health insurance and private for-profit hospitals in the Nordic countries (completed)

By this project, we aim at describing, analysing and discussing the normative aspects of the expansion of voluntary, private health insurance and private for-profit hospitals in a systematic way.

About the project

The project is built upon seven work packages; three covering the analyses of VPHI, three covering the analyses of private for-profit hospitals and one covering the normative aspects of the observed trends:

WP1: Theoretical discussion of the VPHI market
WP2: Supply and demand for VPHI among individuals and firms
WP3: VPHI and out-of-pocket payment as “top up” funding mechanisms in specialist care – selection effects
WP4: Theoretical discussions of the regulation of private providers
WP5: The supply and demand for services from private for-profit hospitals
WP6: Use of public and private hospitals – effects on patient selection and quality
WP7: Normative aspects of mixed private-public welfare state

For each of the WPs we present topics, research questions and choice of methods in detail. Data will primarily, be collected in Norway, Denmark and Finland.

Background

The growth of voluntary private health insurance and private for-profit hospitals raises a number of important questions about the welfare states.

The European welfare states are facing considerable economic challenges. An increased pressure on public financing has strengthened the need to find political responses without jeopardizing the core principles of the welfare state.

Two policy options under development, also in the Nordic countries, are:

a) to increase the use of private financing of welfare services via voluntary, private health insurance (VPHI) and

b) to open up for private for-profit hospitals in provision of health-care services either funded through VPHI, out-of-pocket payments or public budgets.

Objectives

A turn to private financing of welfare services represents a shift to a more individualistic way of financing welfare and a more direct link between payments and benefits. A more fundamental shift in funding and organizing of health-care services might be under way, but up until now, there has been limited systematic comparative knowledge about the topic.

Outcomes

The research finding will be of relevance for governmental agencies in Norway, Denmark and Finland, primarily the Ministries of health, national and regional health authorities, health enterprises and hospitals. There will written academic reports in the working paper series at Institute of Health and Society (University of Oslo) and in academic journals (national and international). The University of Oslo have four study programs where information from the project will be disseminated – all these programs recruit and produce future decision makers for health-care sector. Further, results will be communicated at relevant conferences.

Financing

The project’s total budget is 5,5 mill NOK. 3,6 million is founded by the Norwegian Research Council.

Cooperation

Start – Finish

2014 -- 2018

Tynkkynen, Liina-Kaisa; Alexandersen, Nina; Kaarbøe, Oddvar Martin; Anell, Anders; Lehto, Juhani S. & Vrangbæk, Karsten (2018). Development of Voluntary Private Health Insurance in Nordic Countries. An Exploratory Study on Country-specific Contextual Factors. Health Policy. ISSN 0168-8510. 122(5), p. 485–492. doi: 10.1016/j.healthpol.2018.03.008. Full text in Research Archive
Holom, Geir Hiller; Alexandersen, Nina; Goldhaber-Fieber, Jeremy D. & Hagen, Terje P. (2018). 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. ISSN 2044-6055. 8(6), p. 1–10. doi: 10.1136/bmjopen-2017-019780. Full text in Research Archive Show summary
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 utilising 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 (6 297), or hallux valgus (2 135) from 2009–2014. 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 to 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.
Holom, Geir Hiller & Hagen, Terje P. (2017). 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 arthroplasty. BMJ Open. ISSN 2044-6055. doi: 10.1136/bmjopen-2016-015771. Full text in Research Archive Show summary
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.
Hagen, Terje P.; Holom, Geir Hiller & Ameyu, Kebebew Negera (2017). Outsourcing day surgery to private for-profit hospitals: the price effects of competitive tendering. Health Economics, Policy and Law. ISSN 1744-1331. 13, p. 50–67. doi: 10.1017/S1744133117000019. Full text in Research Archive Show summary
Setting prices for elective patient treatments in private for-profit (PFP) hospitals in traditional tax-funded health systems is challenging since both the organisation of these hospitals and the tasks they perform differ considerably from what we find in public hospitals. From the year 2000, Norway became one of a few countries to gradually implement a procurement system based on competitive tendering when outsourcing elective surgery. In this study we analyse the effect of introducing competitive tendering on the prices paid to PFP hospitals. Pricing data were collected from the formal contracts awarded to PFP hospitals and defined in terms of both absolute and relative prices. We found that PFP hospitals performed day surgeries at markedly lower prices than public hospitals and that competitive tendering triggered the price reduction. We speculate that the PFP hospitals’ lack of acute services, less severe patient population, reduced teaching responsibilities and ability to streamline production, as well as other factors, explain the lower prices at PFP hospitals.
Alexandersen, Nina; Hagen, Terje P. & Kaarbøe, Oddvar Martin (2017). Hvilke bedrifter kjøper private helseforsikringer i Norge? Samfunnsøkonomen. ISSN 1890-5250. 1, p. 31–38. Show summary
I underkant av 500 000 personer har private helseforsikringer i Norge, de fleste gjennom arbeidsgiverfinansierte kollektive ordninger. Forsikringene skal primært gi raskere tilgang til spesialisthelsetjenester. Vi bruker data fra en spørreundersøkelse supplert med registerdata fra Brønnøysundregistrene og analyserer sannsynligheten for å ha privat helseforsikring. Vi finner at sannsynligheten for private helseforsikringer øker med antall ansatte og med andel menn i bedriften, men reduseres med sykefravær på næringsnivå. Arbeidsgivers avgjørelse om å kjøpe private helseforsikringer er påvirket av ansattes preferanser og arbeidsgivers oppfatning om at private helseforsikringer kan brukes som rekrutteringsstrategi. I gjennomsnitt er bedriftene fornøyd/veldig fornøyd med det medisinske tilbudet som gis gjennom private helseforsikringer.
Alexandersen, Nina; Anell, Anders; Kaarbøe, Oddvar Martin; Lehto, Juhani S.; Tynkkynen, Liina-Kaisa & Vrangbæk, Karsten (2016). The development of voluntary private health insurance in the Nordic countries. Nordic Journal of Health Economics. ISSN 1892-9729. 4(1), p. 68–83. doi: 10.5617/njhe.2718.

View all works in Cristin

Vrangbæk, Karsten (2018). Private sundhedsforsikringer og private sygehuse i Danmark .
Lehto, Juhani S. & Hagen, Terje P. (2018). HEALTH AND SOCIAL CARE SYSTEM REFORM IN FINLAND perspectives on private insurance and private hospitals.
Hagen, Terje P. (2018). Privatisering av helsetjenester i Norden - hovedkonklusjoner.
Vrangbæk, Karsten (2018). Litteraturreview - er private sygehuse mere effektive end offentlige .
Holom, Geir Hiller (2018). Hvem benytter private kommersielle sykehus.
Kaarbøe, Oddvar Martin (2018). Hva kjennetegner bedrifter som kjøper private helseforsikringer i Norge.
Hagen, Terje P. (2017). Privatisering på norsk. Anbudskonkurranser, seleksjon og kvalitet i en skattefinansiert helsetjeneste.
Hehenkamp, Burkhard & Kaarbøe, Oddvar Martin (2017). Location Choice and Quality Competition in Mixed Hospital Markets.
Kaarbøe, Oddvar Martin (2017). Location choice and quality competition in mixed hospital markets.
Tynkkynen, Liina-Kaisa; Alexandersen, Nina; Kaarbøe, Oddvar Martin; Anell, Anders; Lehto, Juhani S. & Vrangbaek, Karsten (2017). Development of Voluntary Private Health Insurance in Nordic Countries – An Exploratory Study on Country-specific Contextual Factors.
Holom, Geir Hiller; Alexandersen, Nina & Hagen, Terje P. (2017). Which patients receive surgery in for-profit and non-profit hospitals in a universal Health system? An explorative register-based study.
Kaarbøe, Oddvar Martin (2016). Location Choice and Quality Competition in Mixed Hospital Markets.
Kaarbøe, Oddvar Martin (2016). Privata sjukvårdsförsäkringar i Norden – vilka är köparna och vilka effekter får dom?
Alexandersen, Nina; Hagen, Terje P. & Kaarbøe, Oddvar Martin (2016). Hvilke bedrifter kjøper private helseforsikringer i Norge?
Kaarbøe, Oddvar Martin (2016). Location choice and quality competition in mixed hospital markets.
Kaarbøe, Oddvar Martin (2016). Hvilke bedrifter kjøper private helseforsikringer i Norge?
Holom, Geir Hiller (2016). Big Data in Norway.
Holom, Geir Hiller (2016). Patient selection in private for-profit, private non-profit, and public hospitals using Norwegian big data.
Holom, Geir Hiller (2016). Which Patients Receive Surgery in For-Profit and Non-Profit Hospitals in a Universal Health System?
Kaarbøe, Oddvar Martin (2015). Location choice and quality competition in mixed hospital markets.
Kaarbøe, Oddvar Martin (2015). Location choice and quality competition in mixed hospital markets.
Kaarbøe, Oddvar Martin; Hagen, Terje P. & Aleksandersen, Nina (2016). Hvilke bedrifter kjøper private helseforsikringer i Norge? 7Letras.