Research

Work in progress

  • Spending the Night? Provider Incentives, Capacity Constraints and Patient Outcomes
Healthcare payment polices have consequences for both fiscal spending and patient health, yet evidence on provider incentive responses remains scarce. This paper studies the effects of a change in the payment scheme for hospitals in Norway. In 2010, payments for stays lasting longer than one day were substantially increased, while payments for patients discharged on the day of admission were decreased. This gave hospitals incentives to shift patients from one-day stays to two-day stays, or to decrease the volume of one-day stays. I study hospital responses by exploiting the variable size of price changes across diagnoses in a difference-in-differences framework, and account for marginal costs of overnight stays through a measure of time-varying capacity constraints. I find no evidence that hospitals respond to price changes. Results imply that the current payment policy yields little scope for policymakers to affect healthcare spending and treatment choices.Geographic variation in healthcare utilization has raised concerns of possible inefficiencies in healthcare supply in high utilization regions, as these regions typically do not achieve better health outcomes. However, geographic variation in utilization could also reflect variation in the demand for healthcare, arising from differences in patient health, preferences or sorting. In this paper, we analyze regional variation in a nationalized, single payer healthcare system, exploiting migration across hospital regions to identify the relative impacts of patient and place factors. Using detailed patient data covering the entire Norwegian population during 2008-2013, we find that place-specific factors account for roughly half of the total difference between average utilization in high and low utilization regions, while the rest is explained by patient characteristics. We further link the estimated place factors to all-cause mortality, and find no significant association. However, higher place effects are associated with a statistically significant reduction in cancer deaths. More generally, higher place effects tend to predict lower mortality from relatively utilization-intensive causes of death, suggesting that high supply regions may in fact achieve modestly improved health outcomes.
  • Waiting for Surgery: Effects on Health and Labor Supply (with Anna Godøy, Venke F Haaland and Mark Votruba)
In universal health care systems, patients often face significant wait times for treatment when capacity constraints are binding. In this paper, we estimate the effects of wait time for orthopedic surgery (days from referral to surgery) on health and labor market outcomes, using patient data covering all publicly funded orthopedic surgeries in Norway referred in 2010 and 2011. As the system assigns higher priority to more urgent cases, naive OLS estimates linking observed wait times to individual patient outcomes could reflect selection bias. Our identification strategy exploits quasi-random variation in wait times for surgery generated by the idiosyncratic variation in system "congestion" at the time of a specific patient's entry into the queue. Precisely, we instrument a patient's wait time by the average wait time of other patients queued for the same procedure at the same hospital around the same time. We find that longer wait times for surgery significantly increase health related work absence: For every 10 days spent waiting for surgery, sick leave in the two years following referral increases by about 3 days. Moreover, longer wait times do not appear to have any lasting health implications.
  • Universal Breast Cancer Screening and Mortality
This paper studies effects of universal breast cancer screening with mammography on mortality. The Norwegian mammography program is exploited to estimate effects of (invitation to) screening on women's all-cause mortality. A staggered implementation structure provides spatial and temporal variation in invitation to screening. Results indicate that mammography screening has no significant effect on all-cause mortality.


Publications

  • S.A.C. Kittelsen et al. (2015). Costs and quality at the hospital level in the Nordic countries. Health Economics