Norwegian Hospital Reform Research Articles

Assessing physician productivity following Norwegian hospital reform: A panel and data envelopment analysis

BackgroundAlthough health care reforms may improve efficiency at the macro level, less is known regarding their effects on the utilization of health care personnel. Following the 2002 Norwegian hospital reform, we studied the productivity of the physician workforce and the effect of personnel mix on this measure in all nineteen Norwegian hospitals from 2001 to 2013. MethodsWe used panel analysis and non-parametric data envelopment analysis (DEA) to study physician productivity defined as patient treatments per full-time equivalent (FTE) physician. Resource variables were FTE and salary costs of physicians, nurses, secretaries, and other personnel. Patient metrics were number of patients treated by hospitalization, daycare, and outpatient treatments, as well as corresponding diagnosis-related group (DRG) scores accounting for differences in patient mix. Research publications and the fraction of residents/FTE physicians were used as proxies for research and physician training. ResultsThe number of patients treated increased by 47% and the DRG scores by 35%, but there were no significant increases in any of the activity measures per FTE physician. Total DRG per FTE physician declined by 6% (p < 0.05). In the panel analysis, more nurses and secretaries per FTE physician correlated positively with physician productivity, whereas physician salary was neutral. In 2013, there was a 12%–80% difference between the hospitals with the highest and lowest physician productivity in the differing treatment modalities. In the DEA, cost efficiency did not change in the study period, but allocative efficiency decreased significantly. Bootstrapped estimates indicated that the use of physicians was too high and the use of auxiliary nurses and secretaries was too low. ConclusionsOur measures of physician productivity declined from 2001 to 2013. More support staff was a significant variable for predicting physician productivity. Personnel mix developments in the study period were unfavorable with respect to physician productivity.

Public sector reform and blame avoidance effects

AbstractBlame avoidance has often been claimed to be an important rationale behind changes in the organisation of the public sector, but very few studies have examined whether and how public attribution of responsibility is actually affected by such reforms. For instance, how do changes in the formal allocation of authority affect public attribution of blame when things go wrong? Is the effect immediate or delayed? To advance our understanding of such questions, this paper presents an analysis of blame and credit attribution in more than 1,200 newspaper articles about health-care-related issues in Norway before and after the major Norwegian hospital reform from 2002. The central empirical finding of the article is that central state-level authorities in Norway were attributed less blame in media coverage of health-care problems after the reform than before the reform. The shift is delayed, but substantial and robust to various modifications in model estimations.

Sammenslåing av tre sykehus til ett universitetssykehus

The merging of hospitals into health enterprises ensued from the Norwegian hospital reform of 2002. A complex restructuring process lasting from 2007 to 2009 resulted in the merger of three hospitals into the University Hospital of North Norway. Clinical activities were reorganised into fewer and larger units (divisions) and changed from in-patient to day treatment. Leadership was established across geographic units, and a programme for improving patient care pathways was launched. The experience gained is described by means of activity data from January 2006 to April 2011. The number of patient contacts in the somatic sector was temporarily reduced by 7 % in 2009. The mean waiting period increased from 80 days in 2006 to 108 days in 2010, but fell to 85 days in 2011. In psychiatry and specialised cross-disciplinary addiction therapy, the number of patient contacts increased, and waits were unchanged or shortened. National quality indicators showed unchanged or improved results. The number of scientific publications increased by 62 %. Productivity (DRG points per employee-month) increased from 0.73 to 0.79. The annual financial outcome was improved by NOK 537 million (12 % of the 2006 budget). 81 % of the employees were satisfied with their jobs after the restructuring. We maintained activity and the quality of patient treatment at a high level through the change period, and the hospital's financial position has improved. The methods used do not allow conclusions on possible causal relationships between the change process and the results achieved in core activities.

Patient rehabilitation in hospitals a prioritized discipline after hospital reform: a Norwegian perspective

The purpose of the present study was to highlight the effects of hospital reform introduced in Norway 2002 on patient rehabilitation. The Norwegian hospital reform is an activity-controlled financing system with diagnosis-related groups (DRG). A multi-case study with embedded design methods was used. Document analysis and interviews are sources of evidence. The rehabilitation service offered a treatment service that was inadequately funded. The focus of the rehabilitation team was negatively affected by the lack of organization. The different patient groups did not receive optimal and individualized rehabilitation as required by individual treatment plans. There were two different levels of rehabilitation at the hospitals. The financing system did not provide for a differentiated treatment service tailored to each patient's individual plan, as stipulated by health policy. An increase in the number of patients receiving rehabilitation in the health authorities was not accompanied by an increase in allocated resources, leading to an insufficient overall rehabilitation service. The organizations included in the case study were not those who finance specialized rehabilitation at specialized rehabilitation centres. Specially trained nurses are strategically placed to shape and influence funding of rehabilitation programmes through leadership.

The politics of local hospital reform: a case study of hospital reorganization following the 2002 Norwegian hospital reform.

BackgroundThe Norwegian hospital reform of 2002 was an attempt to make restructuring of hospitals easier by removing politicians from the decision-making processes. To facilitate changes seen as necessary but politically difficult, the central state took over ownership of the hospitals and stripped the county politicians of what had been their main responsibility for decades. This meant that decisions regarding hospital structure and organization were now being taken by professional administrators and not by politically elected representatives. The question raised here is whether this has had any effect on the speed of restructuring of the hospital sector.MethodThe empirical part is a case study of the restructuring process in Innlandet Hospital Trust (IHT), which was one of the largest enterprise established after the hospital reform and where the vision for restructuring was clearly set. Different sources of qualitative data are used in the analysis. These include interviews with key actors, observational data and document studies.ResultsThe analysis demonstrates how the new professional leaders at first acted in accordance with the intentions of the hospital reform, but soon chose to avoid the more ambitious plans for restructuring the hospital structure and in fact reintroduced local politics into the decision-making process. The analysis further illustrates how local networks and engagement of political representatives from all levels of government complicated the decision-making process surrounding local structural reforms. Local political representatives teamed up with other actors and created powerful networks. At the same time, national politicians had incentives to involve themselves in the processes as supporters of the status quo.ConclusionBecause of the incentives that faced political actors and the controversial nature of major hospital reforms, the removal of local politicians and the centralization of ownership did not necessarily facilitate reforms in the hospital structure. Keeping politics at an arm's length may simply be unrealistic and further complicate the politics of local hospital reforms.

Deficits, Soft Budget Constraints and Bailouts: Budgeting after the Norwegian Hospital Reform

In the 1990s, the Norwegian hospital sector was characterized by soft budgetary constraints and increasing budget deficits. This was one of the main antecedents of the 2002 hospital reform, where the central state took over ownership of the hospitals from the counties. Arguably, the centralization of ownership, financing and production would harden the budget constraints and increase the budgetary discipline. This analysis shows that this has not been accomplished. Instead, the production has been far above what was planned, and the deficits higher than ever. Two stages of the post‐reform budget processes are analyzed: first, the stage where the central state set the budgets and sends signals of budgetary rules (whether the state sends signals of soft or hard budget constraints), and second, how the central state handled deficits in the hospital sector as they emerged (whether the hospitals was bailed out or not). The conclusion is that the central state neither set a hard budget constraint nor managed to stay firm as deficits turned up. It is argued that three mechanisms explain the prevailing problems of managing the hospital sector: uncertainty of the hospitals’ financial situation during the transition phase; minority governments; and specific features related to the organization of the budgetary process in parliament.

Centralized or decentralized? A case study of Norwegian hospital reform

In recent years, decentralization of financial and political power has been perceived as a useful means to improve outcomes of the health care sector of many European countries. Such reforms could be the result of fashionable policy trends, rather than being based on knowledge of “what works”. If decentralization is the favored strategy in health care, studies of countries that go against the current trend will be of interest and importance as they provide information about the potential drawbacks of decentralization. In Norway, specialized health care has recently been recentralized. In this paper, we review some of the evidence now available on the economic effects of recentralization. Although recentralization has been associated with improvements in both cost efficiency and technical efficiency this may have been caused by the increasing role of activity-based funding methods used in the allocation of health care resources. However, recentralization was also associated with an increase in the rate of growth of real resources and the proportion of total costs being met by supplementary funding. As a result, recentralization failed to address the issues of cost containment and reductions in budget deficits.

Private or public? An empirical analysis of the importance of work values for work sector choice among Norwegian medical specialists

In the aftermath of the Norwegian hospital reform of 2002, the private supply of specialized healthcare has increased substantially. This article analyses the likelihood of medical specialists working in the private sector. Sector choice is operationalized in two ways: first, as the likelihood of medical specialists working in the private sector at all (at least 1% of the total work hours), and second, as the likelihood of working full-time (90–100%) privately. The theoretical framework is embedded in work values theory and the results suggest that work values are important predictors of sector choice. All analyses are based on a postal questionnaire survey of medical specialists working in private contract practices and for-profit hospitals and a control group of specialists selected from the Norwegian Medical Association's member register. The analyses revealed that while autonomy values impact positively on the propensity for allocating any time at all to the private sector, professional values have a negative effect. Given that the medical specialist already works in the private sector, a high valuation of professional values and payment and benefit values increases the likelihood of having a dual sector job rather than a full-time private position. However, due to the cross-sectional structure of the data and limitations in the dataset, causality questions cannot be fully settled on the basis of the analyses. The relationship between work values and sector choice should, therefore, be regarded as associations rather than causality links. Finally, the likelihood of working in the private sector varies significantly at the municipality level, suggesting that medical specialist's location is important for sector choice.

Performance Management and Public Sector Reform: The Norwegian Hospital Reform

ABSTRACT This article addresses the development of new performance management systems related to public sector reforms. One such system is Management by Objectives and Results (MBOR), based on an official OECD model. Such a system tries to establish unambiguous goals, objectivity, and incentive elements into often traditionally trust-based systems embedded in a complex political-administrative context. To analyze such performance management systems and how they work in practice, we focus on a recent reform of the hospital structure in Norway. Using a broad institutional perspective, we argue that the MBOR-system in Norway is a mixed and complex system encompassing different kinds of logic. These include instrumental elements from the new performance management systems combined with ad hoc preventive efforts by the political leadership, the influence of cultural constraints, elements of rather inappropriate self-interested action, and pressure from the environment. The study reveals that the hospital reform in Norway in practice can be seen as an integrated model, combining informal trust-based approaches and formal performance management measures. It also shows that negative side effects and dysfunctions might occur.

The Norwegian Hospital Reform: Balancing Political Control and Enterprise Autonomy

This essay focuses on the balance between governmental control and enterprise autonomy by examining the Norwegian hospital reform. We describe the enterprise model and give a description of the policy instruments that the government, as owner, has for exercising power and control vis-à-vis the health enterprises. How the trade-off between autonomy and control is experienced and practiced is analyzed from an instrumental, an institutional, and an environmental perspective. The database comprises a survey collected from health enterprise executives and illustrative cases. The trade-off can be characterized as ambiguous and unstable and we ask whether it is possible to achieve a strategy to more appropriately balance the goals of control and autonomy.

The Norwegian hospital reform of 2002: Central government takes over ownership of public hospitals

Starting in January 2002, the majority of the Norwegian Parliament transferred the ownership of all public hospitals from the county governments to the central state. This round of reforms represents the most recent attempt by the central government to resolve major problems in the Norwegian health care system. In this paper, we describe these reforms and the problems they are intended to remedy. We also indicate further proposals that we believe need to be accomplished to ensure that the reforms become successful. The main lesson to be learned from the Norwegian experiment is that central government involvement in local and county government decision-making can lead to ambiguous responsibilities and a lack of transparency. This appears to be particularly the case when central government involvement implies shared responsibilities for the financing of particular services.

Telemedicine and eHealth in Norway: administration and delivery of services

Objectives. This article reviews the situation in Norway concerning the administration and delivery of telemedicine and eHealth.Methods and results. By introducing the Norwegian hospital reform implemented in January 2002, the review provides the background allowing to understand the shift in strategy within this field in Norway. It also provides a historical context regarding the use and development of telemedicine in Norway. Since the implementation of the hospital reform, it can be argued that, presently, there has been a significant change in strategy from what can be described as a “muddling through”-strategy to a more rational approach, based on common and clearly defined goals.Conclusions. The hospital reform can be regarded as an important crossroads for the use of information and communication technology in Norway. The hypothesis put forward is that the development since the reform was implemented has strengthened both the willingness and the ability to make rational choices and take important steps forwards regarding the use of information and communication technology in the health sector in Norway, when discussing both telemedicine and eHealth.

Accountable Management Reforms: Why the Norwegian Hospital Reform Experiment Got Lost in Implementation

There is an international tendency to replace governmental funding based on fixed grants by different reforms implying accountable management methods. In this article we focus on the implementation problems of New Public Management reforms in the Norwegian hospital sector. These reforms are built on a belief that more accountable methods will improve efficiency and better resource allocation. The term New Public Management includes different cost‐improvement programmes like Prospective Payment Systems, which were introduced as a new basis of funding in four Norwegian hospitals during a three year experimental period. The studies presented here support the findings from similar reforms in other countries, stating that there are very few, if any, documented efficiency gains by these reforms. The explanation may be that the reforms have disregarded the importance of internal organisational processes, like high quality management, communication and participation as parts of the implementation phases.