Supplementing gatekeeping with a revenue scheme for secondary care providers

Abstract

We study implications of a change in the payment scheme for radiology providers in Norway that was implemented in 2008. The change implies reduced fee-for-service and increased fixed budget for a contracted volume of services. A consequence of the change is that private providers have less incentive to conduct examinations beyond the contracted volume. Different from the situation observed before the change in 2008, the volume is no longer determined by the demand side, and a rationing of the supply occurs. We employ data on radiological examinations initiated by GPs' referrals. We apply monthly data at the physician-practice level for 2007-2010. The data set is unique because it includes information about all GPs in the Norwegian patient-list system. The results indicate that private providers conducted fewer examinations in 2008-2010 compared with previous periods and that public hospitals did either the same volume or more. We find that GPs who operate in a more competitive environment experienced a greater reduction in magnetic resonance imaging, both performed by private providers and in total for their patients. We argue that this result supports a hypothesis that patients with lower expected benefits are rationed. Hence, rationing from the supply side might supplement GP gatekeeping.

Effects of a reimbursement change and travel times on the delivery of private and public radiology services in Norway: a register-based longitudinal study of Norwegian claims data

“…Further research is required regarding whether the reduction in total services nationally was due to some of these services being unnecessary (especially in areas where patients had providers close by) or whether people stopped waiting or paying for radiology examinations privately out of pocket [16, 30, 57]. The number of patients using private health insurance increased 12 times from 2006 to 2016, and 30% of such plans were used for specialists and diagnostics [58].…”

“…Visits to a public or private laboratory require a referral from a GP or a specialist to be covered by the National Health Insurance (NHI) [29]. In theory, radiology laboratories can decline to make an appointment, but in practice, this does not happen often because GPs already act as gatekeepers [30].…”

Overutilization of Imaging Tests and Healthcare Fairness

“…Paying attention to such mechanisms is crucial when addressing overutilization of imaging. In addition to strategies towards the professionals, more attention should be paid to organizational aspects like, ownership of equipment (Hong et al 2017) and payment scheme (Iversen and Mokienko 2016). Fortunately, the international Choosing Wisely campaign (Levinson et al 2015) together with other measures to reduce overuse have shown that it is possible to address overutilization of radiological services.…”