Sickness Insurance System Research Articles

Institutionalizing suspicion: Tracing the decline of the Swedish sickness insurance system in the 2000’s

This article presents an analysis of Swedish sickness insurance in the 2000’s, outlining cultural and structural shifts in political and institutional design. The study is based on analytic dualism and Margaret S. Archer’s morphogenetic model, which is used to create an analytical narrative focusing on political and institutional developments. The narrative identifies two distinct phases: one period of rapid cultural and structural change (morphogenesis), and one of institutionalization of the new structure (morphostasis). The narrative describes how a key element of the Swedish welfare state, sickness insurance, underwent a transition from an encompassing and generous to a strict and suspicious system, and how this was effectively solidified politically and organizationally. This is related both to a broader shift toward neoliberal and workfare policies, and to the specific socio-cultural and social interactions between agents to reform the system. The analysis provides a contribution to the literature by providing an internationally relevant empirical case of how an encompassing system has undergone a period of substantial decline, and by presenting a coherent long-term narrative which temporalizes this development into specific timepoints and phases.

The cost of saying no: general practitioners’ gatekeeping role in sickness absence certification

BackgroundGeneral practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.MethodsQualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke’s thematic analysis approach.ResultsOur results indicate that GPs’ sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs’ opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs’ available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence.ConclusionOur study suggests that GPs’ decisions about sickness certification is largely driven by patient preferences. The GPs’ gatekeeping function is limited to negotiations about grade and duration of absence spells.

Social Insurance Literacy Among the Sick-listed-A Study of Clients' Comprehension and Self-Rated System Comprehensibility of the Sickness Insurance System.

Sickness insurance systems and their processes have been studied in terms of transparency, comprehensibility and fairness, highlighting the importance of just procedures that make sense to clients. Related research demonstrates differences between groups of clients, pointing towards a social gradient. The concept of social insurance literacy and the Social Insurance Literacy Questionnaire (SILQ) was recently developed and serves as a measure for client's ability to obtain, understand and act on information in a sickness insurance system, relating to the comprehensibility of the information that the system provides. The purpose of this study was to investigate social insurance literacy among clients on sick leave and its associations with perceived justice, being granted sickness benefits and background factors. This was a questionnaire study with clients on sick leave in Sweden. In the selection process 3993 clients were invited, of which 1173 recently had their sickness benefits withdrawn. Those who answered the SILQ (n = 1152) also answered a perceived justice measure and accepted sharing register data from the Swedish Social Insurance Agency. Data were analyzed through regression analysis. The findings demonstrate that clients' perceptions of system comprehensibility and the status of their sick leave case was significantly associated with perceived justice, and being granted sickness benefits, while their individual abilities to obtain, understand, and act on information had lesser influence. The system's ability to provide understandable information seems more important than clients' abilities to comprehend it. From a client perspective, a just system seems to be related to their experiences of the sick leave process (i,e., whether they had an ongoing or closed case) rather than their skills to obtain the correct information.

Exploring Interactions in the Sickness Insurance System in Terms of Power and Trust

Purpose Activation policies and efforts to reduce sick leave rates has influenced sickness insurance systems in Western countries, which has led to social security being more connected with work and attempts to expose malingering among the sickness absent. The aim of this study was to explore how power and trust are expressed by clients and stakeholders within the Swedish sickness insurance system. Methods This was a longitudinal qualitative study based on semi structured interviews and case files from 31 clients on sick leave in Sweden. Data was analyzed using a thematic analysis. Results The main theme ‘Acts of power and distrust’ illustrates how stakeholders’ express suspicions towards each other, and how clients need to demonstrate desire and efforts to return to work which other stakeholders verified. Conclusions The clients desire to prove themselves able to contribute to society was prominent in this study and power relations need to be acknowledged, in particular between client and the SIA. Further, to preserve citizens trust in the system, the system needs to demonstrate trust also in the clients.

Overview of recent cases before the Court of Justice of the European Union (March 2021-September 2021)

In O.D. and Others v INPS (C-350/20), the Court dealt with the refusal of the Italian authorities to grant childbirth and maternity allowances to third-country nationals falling within the scope of the Single Permit Directive. In CG (C-709/20), the Court considered the refusal of the UK authorities to grant social assistance to an economically inactive EU citizen resident under the UK scheme adopted in the context of Brexit. In AB v Olympiako (C-511/19), the Court found that the Greek legislation, adopted in the context of the economic crisis, placing public sector workers in a labour reserve system is not discriminatory on grounds of age. In WABE and MH Müller Handel (C-804/18 and C-341/19), the Court clarified what circumstances could justify differential treatment indirectly based on religion or belief. The Court confirmed the direct effect of the principle of equal pay for male and female workers enshrined in Article 157 TFEU for cases of work of equal value in Tesco Stores (C-624/19). In Team Power Europe (C-784/19), the Court specified under which criteria a temporary-work agency could be considered as pursuing ‘substantial activities’ in a Member State. In A (C-535/19), the Court held that a Member State cannot exclude an economically inactive EU citizen from its public sickness insurance system but does not have to grant access free of charge. In FORMAT (C-879/19), the Court confirmed that Article 14(2) of Regulation 1408/71 does not apply to a person who, under a single employment contract concluded with a single employer, works in several Member States for more than 12 months in each of those Member States. Finally, in PF (C-27/20), the Court dealt a national legislation which uses the penultimate year preceding the payment period as the reference year for the calculation of family allowances to be allocated.

Social validity of work ability evaluations and official decisions within the sickness insurance system: A client perspective.

BACKGROUND:Studies of the social validity of work ability evaluations are rare, although the concept can provide valuable information about the acceptability, comprehensibility and importance of procedures.OBJECTIVE:The aim of this study was to explore clients’ perceptions of social validity of work ability evaluations and the following official decisions concerning sickness benefits within the Swedish sickness insurance system.METHODS:This was a longitudinal qualitative study based on interviews with 30 clients on sick leave, analyzed through deductive content analysis.RESULTS:Clients’ understanding of the evaluation was dependent on whether the specific tests were perceived as clearly related to the clients’ situation and what information they received. For a fair description of their work ability, clients state that the strict structure in the evaluation is not relevant to everyone.CONCLUSION:The work ability evaluations indicate low acceptability due to lack of individual adaptation, the comprehensibility varied depending on the applicability of the evaluation and information provided, while the dimension ‘importance’ indicated as higher degree of social validity. The official decision about sickness benefits however was considered unrelated to the evaluation results, lacking solid arguments and sometimes contradictory to other stakeholders’ recommendations indicating poor social validity.

How People with Multimorbidity and Psychosocial Difficulties Experience Support by Rehabilitation Coordinators During Sickness Absence.

PurposePeople with multimorbidity face a range of barriers in healthcare, and there is little knowledge about their challenges with regard to return-to-work (RTW). Rehabilitation coordinators, a new function in Swedish healthcare, support people in the RTW process. The present study had two aims: to explore what problems and barriers people with multimorbidity experience during their rehabilitation and RTW process and to explore in which domains the coordinators’ support is perceived to be of importance.MethodsInterviews were conducted with 12 persons with multimorbidity who had contact with a rehabilitation coordinator during their sickness absence. Thematic analysis was guided by the case-management ecological model; this analysis was revised and adapted to the Swedish context.ResultsThe participants experienced problems in all domains of the model, namely: “the healthcare system”, “the labor market and the workplace system”, “the sickness insurance system”, and “the personal system”. Rehabilitation programs that did not accommodate combinations of diseases, social complexities and needs were felt to lead to worse symptoms, thus hindering rather than promoting RTW. An overall finding regarding support by coordinators is that interventions, regardless of domain, were felt to be valuable for people with multimorbidity. The coordinator was perceived to give most support by providing advice about and coordination with healthcare and employers. Sometimes the coordinator gave advice and coordination regarding the Social Insurance Agency, very occasionally the Public Employment Services. The coordinator gave least advice and coordination about social difficulties that hindered rehabilitation and RTW processes.ConclusionPeople with multimorbidity perceive rehabilitation coordinator interventions as important in all domains investigated. Lack of advice and coordination, or rehabilitation programs that were not modified to the complexities of individual’s circumstances, were associated with prolonged sickness absence, worse health, or social risk factors not being recognized.

Social Workers’ Compensation Models and the Czech Statutory Employer Liability Insurance

Abstract Czech workers’ compensation is “exemplified” by the adoption of the Worker’s Accident Insurance Act in 2006, four deferments of its effective date and then complete annulment of the Act. A temporary settlement aimed at resolving the incompatibility of the communist model of workers’ compensation for work accidents and occupational illnesses with the transition to a market economy after 1989 involved the implementation of statutory employer liability insurance for work accidents and occupational illnesses, outsourced to two private insurance companies; the current Czech government does not seem to have a know how to deal with it. The objective of this paper is primarily to advise the government using primarily the formulation and comparison of four basic social workers’ compensation models and furthermore considering the existing sickness, pension and health insurance systems. The choice of a social model is namely a matter of public choice, but intensive lobbying also constitutes part of these processes. The analyses result in a recommendation to “dissolve” the statutory employer liability insurance into a jointly collected social insurance contribution for sickness and pension insurance, and partly to transform the current accident benefits into increased sickness and pension benefit assessments and partly to cancel them.

Social validity for work ability assessments and official decisions – clients’ experiences

Abstract Background Professionals need to be able to express what is at stake during the decision-making process and the discrepancy between formal rules and practical rationality need to be bridgeable and transparent for outsiders. Investigations of social validity for work ability assessments are rare. However, the concept can provide valuable information upon the acceptability and comprehensibility of procedures and how professionals can increase clients’ participation. The purpose of this study was to investigate social validity for work ability evaluations within the sickness insurance system and the official decisions they lead to. Methods This was a longitudinal qualitative study using telephone interviews and files from the Swedish Social Insurance Agency. Clients (n = 30) were interviewed after their participation in a work ability evaluation as well as after receiving an official decision upon eligibility for sickness benefits. Data was analyzed using a deductive content analysis. Results Preliminary findings show that clients’ comprehensibility of the different tests and their composition were depending on whether the specific tests were perceived as clearly related to the clients’ difficulties and what information they had received. In order to receive a fair description of the client’s work ability, clients state that the work ability evaluation needs to be individually adapted and that the standardized structure is not relevant for all. What is acceptable and fair to one client could be unacceptable to another, depending on what arguments and information case-managers and evaluation professionals provided. Conclusions Authorities need to express and motivate the reasons for a diverse range of steps during clients sick-leave process, not only regarding official decisions. Social validity for work ability evaluations is depending on the provided information and the applicability to the clients’ situation. Key messages Social validity is depending on the provided information and the applicability to the clients’ situation. Authorities need to communicate clearly with clients through the whole sick-leave process.

Forward-looking moral hazard in social insurance

This study tests for forward-looking moral hazard in the sickness insurance system by exploiting a 1991 reform in Sweden. The replacement rate was reduced for short absences but not for long absences, which introduced a potential future cost of returning to work. Using this exogenous variation in the replacement rate and controlling for dynamic selection, we find that the potential future cost of returning to work decreased the outflow from long-term sickness absence. This finding suggests that long-term sickness absentees respond to economic incentives and are forward-looking, which highlights the importance of taking forward-looking behavior into account when designing and evaluating social insurance programs.

Communication characteristics between clients and stakeholders within the Swedish sickness insurance system – a document analysis of granted and withdrawn sickness benefit claims

Purpose: The purpose of this study was to investigate how communication within the Swedish sickness insurance system differs between cases of sick leave and how this may affect clients’ cases.Materials and methods: This was a document study using 30 client files from the Swedish Social Insurance Agency (SIA). The clients included had been on a work ability evaluation during their sick leave spell and were aged 32–64 years. The material was analyzed using qualitative document analysis.Results: The results show different approaches to communication, characterized by emotional argumentation, matter-of-fact driven argumentation and information exchange, which have diverse success in affecting official decisions. Arguments characterized by emotions such as frustration or desperation are to a larger extent neglected by the authorities compared to those characterized by a matter-of-fact driven approach and referring to regulations and medical certificates.Conclusion: There are differences regarding how clients and stakeholders communicate the clients’ needs and pre-requisites, and how this affects official decisions. Further research must be carried out in order to establish social insurance literacy, initially for individuals on sick leave within the sickness insurance system, and whether there are differences between diverse groups that could lead to injustices.Implications for rehabilitationWithin a social insurance context, professionals need to provide clients with adequate and individually adapted information in order for procedures to be perceived as comprehensible and manageable by the clients.The support from stakeholders such as the treating physician and/or employer can affect clients’ sick-leave process.Clients’ treating medical professionals can contribute to ensuring that clients rights are met by communicating the clients’ needs to other stakeholders in a formal way.

Early Interventions and Disability Insurance: Experience from a Field Experiment

This paper estimates the effects of early interventions in the Swedish sickness insurance system. The aim of the interventions is to screen and, further to, rehabilitate sick listed individuals. We find that the early interventions – in contrast to what is expected – increase the inflow into disability benefits by around 20 percent. In order to explain the results, we develop a simple theoretical model based on asymmetric information of the health status. The model predicts that the treatment effect is larger for individuals with low incentives to return to work. In order to test this prediction we estimate effects for sick listed employed and unemployed separately. Consistent with the model’s prediction, we find that the effect is larger for the unemployed than for the employed.

Sick-listing adherence: a register study of 1.4 million episodes of sickness benefit 2010-2013 in Sweden.

BackgroundThis register study aims to increase the knowledge on how common it is that sickness benefit recipients are sick-listed for as long as their physician prescribes in their medical sickness certificate, i.e. sick-listing adherence, or wholly/partly bring return-to-work (RTW) forward, i.e. early RTW.MethodsThe unit for analysis was an episode of 100% sickness benefit, commenced between 1 January 2010 and 31 December 2013. Completed episodes of sickness benefit and full or partial early RTW was analysed by comparing the prescribed length of sick leave in medical sickness certificates and benefit days disbursed by the sickness insurance system. Probability for a full and partial early RTW was estimated with hazard ratio (HR) using the Cox proportional hazard model.ResultsIn total, about 1.4 million episodes of sickness benefit (60% women) were included in the study. The overall sick-listing adherence was 84% for women and 82% for men during the first year of sick leave. Adherence varied between 82 and 87% among women and between 79 and 86% among men with regard to ICD-10 diagnosis chapter. The probability of an early RTW varied between diagnosis chapters, where mental disorders was associated with a lower probability of a full early RTW among women and men (HR 0.52 and HR 0.47) as well as a partial early RTW (HR 0.51 and HR 0.46). Younger age (16–29 years), high educational level and high income was associated with a higher probability of an early RTW, while older age (≥50 years), not native-born, low educational level, unemployment and parental leave were associated with a lower probability.ConclusionThe study demonstrates that sick-listing adherence is relatively high. Probability of an early RTW differs with regard to diagnosis chapter, demographic, socioeconomic and labour market characteristics of the sickness benefit recipients. Interventions intended to improve the sick-listing process, and to affect the length and degree of sick leave in certain target groups, should include measures targeted at physicians’ sick-listing practices. Policies and economic incentives aimed at promoting RTW need to focus on individuals’ residual capacity for work.

How common is change of primary diagnosis during an episode of sickness benefit? A register study of medical sickness certificates issued 2010-2012 in Sweden.

The aims of this study were to investigate how common it is to change primary diagnosis between different diagnostic chapters during a sick-leave spell, and to explore patterns of diagnostic changes. The unit for analysis was episode of sickness benefit, that is, sick leave >14 days, which commenced between 2010 and 2012 in Sweden. For each case, the primary diagnosis was retrieved from the first and last/latest medical sickness certificate, respectively. The number of days of sickness benefit was linked to the cases. Any change of primary diagnosis was analysed by diagnostic chapter according to the ICD-10, and this was done separately for women and men. In total, 803,041 cases of sickness benefit (63% women) were included in the study. During a sick-leave spell, 7.1% of female cases and 6.6% of male cases changed their primary diagnosis to a diagnosis from another diagnostic chapter. The change of primary diagnosis increased with the number of days with sickness benefit. For female cases, this increase was from 2.0% for cases that lasted 15-30 days to 20.2% for cases that lasted >365 days. For male cases, the corresponding increase was from 1.8% to 21.2%. A change of primary diagnosis was least common among those initially sick-listed for mental disorders and musculoskeletal disorders. The patterns of diagnostic changes were rather similar for women and men. A change of diagnosis during a sick-leave spell needs to be taken into consideration by the sickness insurance system and in the actions taken by its administration. Registry-based studies of sickness insurance need to consider diagnostic changes in both the study design and the interpretation of results.

The impact of social workers on infant mortality in inter-war Tokyo: Bayesian dynamic panel quantile regression with endogenous variables

Although no comprehensive sickness insurance system existed in Japan until the mid-twentieth century, the infant mortality rate in Japan started to decline from the early twentieth century onwards, specifically owing to health improvements in low-income areas. This paper focuses on the impact of social workers called Homen iin on reducing the infant mortality rate in inter-war Tokyo. These social workers were in charge of the medical casework and provided access to medical treatment for low-income households under the District Committees System. To examine how the activities of these social workers influenced infant mortality, this paper analyses panel data for Tokyo between 1926 and 1937. By employing the dynamic panel quantile regression approach, it is found that the activities of social workers played a vital role in mitigating the risk of infant mortality, especially in areas that had a higher infant mortality rate.

A Kink that Makes You Sick: The Incentive Effect of Sick Pay on Absence

This paper examines the effect of the replacement rule of the Finnish sickness insurance system on the duration of sickness absence. A pre-determined, piecewise linear policy rule in which the replacement rate is determined by past earnings allows identification of the effect using a regression kink design. We find a substantial and robust behavioral response. The statistically significant point estimate of the elasticity of the duration of sickness absence with respect to the replacement rate is on the order of 1.4.

Sick leave and a smoking ban

This editorial refers to ‘Influence of high cardiovascular risk in asymptomatic people on the duration and cost of non-cardiovascular sick leave: results of the ICARIA study’, by E. Calvo-Bonacho et al ., doi:10.1093/eurheartj/eht156 Numerous research projects have been performed during the last decades with the aim to improve the outcome of acute coronary syndrome. Much less effort has been put into optimizinmg the follow-up procedure after an acute life-threatening event such as myocardial infarction. Short- and long-term sickness absence after an acute myocardial infarction is associated with substantial costs for society. We also know that a long sickness absence makes it more difficult for the patient to return to work. There are no clear guidelines as regards the optimal duration and degree of sick leave with this condition, and scientific data guiding doctors are extremely sparse. Furthermore, sick listing practices for heart patients vary considerably among countries. This may be due to various factors, e.g. different sickness insurance systems, labour market conditions, and sick listing traditions among physicians. In Finland and Sweden, about half of patients were available to the labour market 2 years after a myocardial infarction.1,2 Sick leave is used daily by many practitioners. The measure is very costly for society and for most individuals as well. Sickness absence is a complex phenomenon. The three major disease groups in both long-term sick leave and early retirement are musculoskeletal diseases, psychiatric diseases, and cardiovascular (CV) diseases, and the occurrence and course can be influenced by a range of factors, such as age, gender, demographics, physical and mental health, type of work, and personal and organizational factors. Despite widespread consequences of sickness absence, scientific research in this area is quite scarce, partly theoretical, and conceptually …

The Effects of Expanding the Generosity of the Statutory Sickness Insurance System

In 1999, in Germany, the statutory sick pay level was increased from 80 to 100 percent of foregone earnings for sickness episodes of up to six weeks. We show that this reform has led to an increase in average absence days of about 10 percent or one additional day per employee, per year. The estimates are based on SOEP survey data and parametric, nonparametric, and combined matching-regression difference-in-differences methods. Extended calculations suggest that the reform might have increased labor costs by about €1.8 billion per year and might have led to the loss of around 50,000 jobs.

Change and Resilience in Welfare State Policy. The Politics of Sickness Insurance in Norway and Sweden

AbstractThis article compares the processes of reforming sickness insurance in Norway and Sweden. Despite the many similarities between the Norwegian and Swedish welfare states, they have taken different paths when it comes to reforming their sickness insurance systems. In the period between 1990 and 2010 Sweden changed its wage replacement levels and levels of employer financing several times, while in Norway they remain basically unchanged since 1978, notwithstanding many reform initiatives by political authorities. Why have the two cases evolved so differently? We address this question by using Peter Starke's review of the retrenchment literature which outlines four major strands of theorizing the politics of welfare reform: neo‐functionalism, conflict theories, institutionalist theories and discourse theory. Rather than treating these as providing competing explanations, the article suggests that elements from all perspectives bring insights to the case. The need for policy reform must always be communicated in a way that can be understood and approved in order to materialize as actual policy change. But discursive change and apparently seductive frames will not always be enough. This comparative analysis illustrates that the chance of success for new frames or discourses depends on the institutional, political and functional context into which they are inserted. Similar attempts at framing the need for reform and cutbacks have had different effects in the two countries depending on the character of the counter forces and extant frames reformers are up against. On the other hand, over time discourses and frames also shape institutions and political relations.

The Effects of Expanding the Generosity of the Statutory Sickness Insurance System

In 1999, in Germany, the statutory sick pay level was increased from 80 to 100 percent of foregone earnings for sickness episodes of up to six weeks. We show that this reform has led to an increase in average absence days of about 10 percent or one additional day per employee, per year. The estimates are based on SOEP survey data and parametric, nonparametric, and combined matching-regression difference-in-differences methods. Extended calculations suggest that the reform might have increased labor costs by about e1.8 billion per year and might have led to the loss of around 50,000 jobs.