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THL Vaikuttajaseminaari 3.-4.10.2013, Jon Magnussen
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Name, title of the presentation
Norwegian health care reforms of the 2000’s
Jon Magnussen Norwegian University of Science and
Technology Helsinki 3/10 - 2013
Name, title of the presentation
1: Background
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The challenge
Providing high quality health care in an efficient manner within a limited budget, distributing those services equitable across the population
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A Nordic health care model • Tax funding • Decentralized public governance • Elected local governments • Public ownership (or control) of delivery structure • Equity driven, with focus on geographical and
social equity • Public participation.
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Nordic model - similarities
• Common goals and aspirations – Equity ? – Public participation
• Common structural features – Tax based funding – Decentralization – the role of regions, counties and
municipalities – (Local) Political governance
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But: Differences in health policy
• Governance
• Financing and contracting
• Choice
• There is a common model but we differ in how we approach important issues
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2: Norway
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The questions
• Centralized or decentralized governance? – Administrative or political?
• Centralized or decentralized delivery structure? – “A few large – or many small?”
• Payment systems and resource allocation – Efficiency vs. equity
• Coordination of care – Or coordination of providers of care?
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The reforms
• Hospital ownership reform 2002 – The big one!
• List patient reform – GPs 2001 – The uncontroversial one!
• Coordination reform – 2012 – The fuzzy one!
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Norway – year 2000 (i)
• Specialist health care – Responsibility of 19 counties – Mix of activity based payment and global budgets – Counties financed through tax income and
matching state grants – Limited choice of hospital
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Norway – year 2000 (ii)
• Primary health care – Responsibility of 430 municipalities – Salaried GPs – Municipalities financed through tax income and
matching state grants – Free choice of GP
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3: Specialist health care
Hospital reform
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Hospital ownership reform (i)
• Why? Large county variations in per capita spending on health
• Central funding – local provision – Tension (blame games) – Soft budgeting
• Structural issues – Duplication of services (inefficiency) – Quality concerns (low volume)
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Hospital ownership reform (ii)
• State takeover of ownership • Administrative delegation to four Regional
Health Authorities • Regional needs-adjusted distribution of funds • RHAs responsible for investments
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Hospital reform (iii)
• Structural efficiency
• Cost containment
• Geographical equity
• Professional management
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Lessons (i)
• Soft budgeting is difficult to avoid • Deconcentration (administrative decentralization) is
more difficult than devolution (political decentralization) – But may be more effective
• What should be the role of locally elected politicians?
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Lessons (ii)
• Health policy goals and tools need to be internally consistent – ”No growth in activity” – 60 % activity based financing – Free choice of hospitals – Individual treatment guarantee
• Mixed signals creates escape routes and makes governance more difficult
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New government – what now?
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4. Primary health care
List patient reform Coordination reform
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List patient reform – (i)
• Why? Access • What? Everybody joins a GP list – limited
possibility to change GP
• GPs financed 30 % capitation, 70 % FFS • GPs are private contractors with local public
authorities • Number of available “positions” are limited
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List patient reform – (ii)
• Overall the reform has been positively received
• Patients; satisfied – better access to GPs • GPs; (mainly) satisfied – defined patient
population – stable working conditions – higher income
• Municipalities; satisfied – better coordination and planning
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Coordination reform (i)
• Why? To coordinate care between different delivery systems – in particular primary and specialist care
• Why? To ensure that patients are treated at the “lowest efficient” level – i.e. shifting care from specialist to primary health care
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Coordination reform (ii)
• Municipalities paying for hospital care (20 %) • Municipalities paying for patients remaining in
hospitals due to lack of municipal capacity (more than 100%)
• Providing acute care in municipalities • Increased role in prevention
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Coordination reform (iii)
• Number of “discharge ready” patients remaining in hospitals have been drastically reduced
• Increased focus on primary care, but resource implications are still not clear
• Attempts to regulate GPs in more detail have been fiercely opposed
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4: Current policy issues
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Norway – year 2013 (i)
• Specialist health care – Responsibility of state through four regional health
authorities (RHA) – Mix of activity based payment an global budgets – Ear marked financing of RHAs through block
grants and some activity based financing – 20 % municipal co-financing
– Free choice of hospital – including private hospitals
Name, title of the presentation
Norway – year 2013 (ii)
• Primary health care – Responsibility of 430 municipalities – List patient system with GPs financed through
capitation (30%) and activity (70 %) – Municipalities financed through tax income and
matching state grants – Limited choice of GP
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Structure / ownership
• Location of hospitals
• Division of tasks between hospitals
• Small vs large hospitals
• Private vs public hospitals
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Decision making power
• Political vs. administrative decision making
• Local vs. central politicians
• Medicine vs. administrative
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Challenges (i)
• Fiscal sustainability – Tax levels – Share of GDP to health
• Health care as a pure welfare good – Two tier system with a ”public benefit package”
and private services • Priority setting as a logical consequence of
limited resources – At what level and on what grounds?
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Challenges (ii)
• Models of production – Private, public firms, trusts,
• Individual choice vs. public planning
– Equity, ”consumerism”
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Finally – a personal observation
• It is difficult to see differences in underlying values between different political fractions
• Thus, differences are in how (and which) policy tools are used – and even these are often marginal
• Result: Health policy debate is reduced to “simple” rhetoric
• And reforms seems motivated by a need to signal “action” rather than the need to solve a problem..
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Thank you!