Economic incentives and survival probabilities for chronic and multimorbidity patients - Do the relationships depend on patient pathways?

Abstract

Background: The Norwegian Coordination Reform (CR) in 2012 introduced new economic incentives aimed at weaknesses in interaction between primary care, social care and specialist care. This paper studies the association of a new co-payment scheme on the 30-day and 90-day survival probabilities for chronic and multimorbidity patients. We also analyse whether admission types ⸺planned or emergency⸺ matters for survival rates, and the importance of patient pathways. Several different pathways are possible, depending on where patients came from before being admitted to hospital and their destination after discharge from hospital.Methods: The study uses data from three different registers for the period 2010 to 2013. We consider 30 common chronic conditions for which administrative data are available (n=563,096 in-patient episodes). We look at three mutually exclusive pathways. They are relevant and important in terms of the number of patients depending on co-operation and co-ordination between health care providers. Using a quasi-experimental design—the difference-in-differences approach—we estimate the associations between the co-payment scheme and survival probability by admission type and by patient pathway.Results: Overall, the changes in survival probabilities are found positively and significantly associated with the co-payment scheme. For emergency admissions such a significant positive association is observed for the 30-day survival only, whereas, for planned admissions a significant positive relationship is evident for the 90-day survival only. Pathway-specific results indicate positive and significant associations with survival probabilities (both the 30-and 90-day) for all admissions and emergency admissions for two specific pathways. Multimorbidity subgroup analysis generally shows no significant relationship with survival probabilities, but pathway-specific analyses show significant positive associations between emergency admissions and the 90-day survival for patients following two specific pathways. However, for planned admissions we find a significant negative association with the 30-day survival for multimorbidity patients following one specific pathway.Conclusion: We conclude that the survival probabilities are positively associated with the new economic incentives but the result depends on admission type, patient pathway and multimorbidity status. Without modelling admission type, pathway and multimorbidity explicitly, one may overlook important relationships associated with the economic incentives. Future policy evaluations in any pertinent context should envisage these aspects.