Pragmatic randomized controlled trial comparing a complex telemedicine-based intervention with usual care in patients with chronic conditions.

This study evaluates a complex telemedicine-based intervention targeting patients with chronic health problems. Computer tablets and home telemonitoring devices are used by patients to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to answer health-related questions at a follow-up center. We designed a pragmatic randomized controlled trial to compare the telemedicine-based intervention with usual care in six local centers in Norway. The study outcomes included health-related quality of life (HRQoL) based on the EuroQol questionnaire (EQ-5D-5L), patient experiences, and utilization of healthcare. We also conducted a cost-benefit analysis to inform policy implementation, as well as a process evaluation (reported elsewhere). We used mixed methods to analyze data collected during the trial (health data, survey data and interviews with patients and health personnel) as well as data from national health registers. 735 patients were included during the period from February 2019 to June 2020. One year after inclusion, the effects on the use of healthcare services were mixed. The proportion of patients receiving home-based care services declined, but the number of GP contacts increased in the intervention group compared to the control group. Participants in the intervention group experienced improved HRQoL compared to the control group and were more satisfied with the follow-up of their health. The cost-benefit of the intervention depends largely on the design of the service and the value society places on improved safety and self-efficacy.

Exploring physician agency under demand-side cost sharing-An experimental approach.

The assumption of patient-regarding physicians has been widely adopted in the health economics literature. Physicians' patient-regarding preferences are often described as the concern for the health benefits of medical treatments, and thus closely related to the norms and ethics of the medical profession. In this paper, we ask whether physicians' patient-regarding preferences include a concern for their patient's consumption opportunities alongside patient's health benefits. To identify and quantify physicians' preferences, we design and conduct an incentivized laboratory experiment where choices determine separately the health benefits and the consumption opportunities of a real patient admitted to the nearest hospital. We find strong evidence that future physicians care about their patients' consumption opportunities.

Data from an incentivized laboratory experiment on strategic medical choices.

This paper presents data of medical choices determining physicians' profit and patients' health benefit under three levels of market competition: monopoly, duopoly, and quadropoly. The data was collected from 136 German university students in an incentivized laboratory experiment. The designed experimental parameters and the formula for computing the payoff matrices of the games are described in this paper as well. This data was analyzed by Ge and Godager [5] who employed quantal response equilibrium choice  models to investigate the relationship between market competition and determinism in behavior under a quantal response equilibrium paradigm. This data contributes to future investigation on alternative game theoretic equilibrium concepts and the development of empirical methods for studying strategic choice behavior.

The effect of a mystery shopper scheme on prescribing behavior in primary care: Results from a field experiment.

BACKGROUND: Health care systems in many countries are characterized by limited availability of provider performance data that can be used to design and implement welfare improving reforms in the health sector. We question whether a simple mystery shopper scheme can be an effective measure to improve primary care quality in such settings. METHODS: Using a randomized treatment-control design, we conducted a field experiment in primary care clinics in a Chinese city. We investigate whether informing physicians of a forthcoming mystery shopper audit influences their prescribing behavior. The intervention effects are estimated using conditional fixed-effects logistic regression. The estimated coefficients are interpreted as marginal utilities in a choice model. RESULTS: Our findings suggest that the mystery shopper intervention reduced the probability of prescribing overall. Moreover, the intervention had heterogeneous effects on different types of drugs. CONCLUSIONS: This study provides new evidence suggesting that announced performance auditing of primary care providers could directly affect physician behavior even when it is not combined with pay-for-performance, or measures such as reminders, feedback or educational interventions.

Competition, gatekeeping, and health care access.

We study gatekeeping physicians' referrals of patients to specialty care. We derive theoretical results when competition in the physician market intensifies. First, due to competitive pressure, physicians refer patients to specialty care more often. Second, physicians earn more by treating patients themselves, so refer patients to specialty care less often. We assess empirically the overall effect of competition with data from a 2008-2009 Norwegian survey, National Health Insurance Administration, and Statistics Norway. From the data we construct three measures of competition: the number of open primary physician practices with and without population adjustment, and the Herfindahl-Hirschman index. The empirical results suggest that competition has negligible or small positive effects on referrals overall. Our results do not support the policy claim that increasing the number of primary care physicians reduces secondary care.

Profit or patients' health benefit? Exploring the heterogeneity in physician altruism.

This paper investigates physician altruism toward patients' health benefit using behavioral data from Hennig-Schmidt et al.'s (2011) laboratory experiment. In the experiment, medical students in the role of physicians decide on the provision of medical services. The experimental setup allows us to identify the influence of profits and patients' health benefit on the choice of medical treatment. We estimate physician altruism, the weight individuals attach to patients' health benefit, by fitting mixed logit and multinomial logit regression models to the experimental data. Estimation results provide evidence for physician altruism. We find, however, substantial variation in the degree of physician altruism. We also discuss some implications of our results for the design of physician payment schemes in the light of the theoretical literature.

Hospital expenses towards the end of life.

BACKGROUND: International research indicates that a considerable proportion of health expenditure is concentrated in the final phase of life, but to date, reliable Norwegian figures have not been available in this area. The purpose of this study is to investigate the proportion of Norwegian hospital expenditure for outpatient and hospital treatment which is devoted to persons who die in the course of the year. MATERIAL AND METHOD: To estimate the proportion of hospital resources devoted to treatment of patients who die in the course of the year, we use data from the Norwegian Patient Registry, which contains information on all individual treatment episodes of outpatient and hospital treatment in the period 2010, and information from the National Resident Registry on deaths that have occurred during the same year. RESULTS: In total, NOK 4.2 billion, or 10.6% of all hospital expenses for outpatient and hospital treatment in 2010, was devoted to patients who died during the same year. The bulk of the expenses was incurred during the three months immediately prior to death. Hospital expenses towards the end of life declined with increasing age of the patient, and were more than halved for ninety-year-olds compared to seventy-year-olds. More than 50% of the expenses incurred during the last year of life were spent during the three final months of life. INTERPRETATION: These results are relevant for estimating future hospital expenses in the health services. They are also relevant for decision-making related to priorities, but the figures for expenses cannot be used to determine whether too much or too little is spent on a given age group or disease.

Birds of a feather flock together: a study of doctor-patient matching.

In this paper we study individuals' choice of general practitioners (GPs) utilizing revealed preferences data from the introduction of a regular general practitioner scheme in Norway. Having information on relevant travel distances, we compute decision makers' travel costs associated with different modes of travel. Choice probabilities are estimated by means of nested logit regression on a representative sample of Oslo inhabitants. The results support the general hypothesis that patients prefer doctors who resemble themselves on observable characteristics. The hypothesis that GP gender has a stronger influence on females' GP choice than what is the case for males, is rejected.

Dual job holding general practitioners: the effect of patient shortage.

In 2001, a listpatient system with capitation payment was introduced in Norwegian general practice. After an allocation process where each inhabitant was listed with a general practitioner (GP), a considerable share of the GPs got fewer persons listed than they would have preferred. We examine whether GPs who experience a shortage of patients to a larger extent than other GPs seek to hold a second job in the community health service even though the wage rate is low compared with the wage rate in general practice. Assuming utility maximization, we model the effect of patient shortage on a GP's decision to contract for a second job in the community health service. The model predicts a positive relationship between patient shortage and participation in the community health service. This prediction is tested by means of censored regression analyses, taking account of labour supply as a censored variable. We find a significant effect of patient shortage on the number of hours the GPs supply to community health service. The estimated marginal effect is 1.72 hours per week.

Service motives and profit incentives among physicians.

We model physicians as health care professionals who care about their services and monetary rewards. These preferences are heterogeneous. Different physicians trade off the monetary and service motives differently, and therefore respond differently to incentive schemes. Our model is set up for the Norwegian health care system. First, each private practice physician has a patient list, which may have more or less patients than he desires. The physician is paid a fee-for-service reimbursement and a capitation per listed patient. Second, a municipality may obligate the physician to perform 7.5 h/week of community services. Our data are on an unbalanced panel of 435 physicians, with 412 physicians for the year 2002, and 400 for 2004. A physician's amount of gross wealth and gross debt in previous periods are used as proxy for preferences for community service. First, for the current period, accumulated wealth and debt are predetermined. Second, wealth and debt capture lifestyle preferences because they correlate with the planned future income and spending. The main results show that both gross debt and gross wealth have negative effects on physicians' supply of community health services. Gross debt and wealth have no effect on fee-for-service income per listed person in the physician's practice, and positive effects on the total income from fee-for-service. The higher income from fee-for-service is due to a longer patient list. Patient shortage has no significant effect on physicians' supply of community services, a positive effect on the fee-for-service income per listed person, and a negative effect on the total income from fee for service. These results support physician preference heterogeneity.