The 2015 hospital treatment choice reform in Norway: Continuity or change?

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Health Policy

jo u r n al h om ep age :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Health Reform Monitor

The 2015 hospital treatment choice reform in Norway:

Continuity or change?

Ånen Ringard

, Ingrid Sperre Saunes

, Anna Sagan

aTheKnowledgeCentrefortheHealthServices,NorwegianInstituteofPublicHealth,Norway

bUnitedKingdomObservatoryonHealthSystemsandPolices,LSEHealth,UnitedKingdom

a r t i c l e i n f o

Articlehistory:

Received30June2015

Receivedinrevisedform23February2016 Accepted25February2016

Keywords:

Patientchoice Reform Hospital Privateproviders Norway

a b s t r a c t

InseveralEuropeancountries,includingNorway,policestoincreasepatientchoiceofhos- pitalproviderhaveremainedhighonthepoliticalagenda.Themainreasonbehindthe interestinhospitalchoicereformsinNorwayhasbeenthebeliefthatincreasingchoicecan remedythepersistentproblemoflongwaitingtimesforelectivehospitalcare.Priortothe 2013GeneralElection,theConservativePartycampaignedinfavourofanewchoicereform:

“thetreatmentchoicereform”.Thisarticledescribesthebackgroundandprocessleading uptointroductionofthereformintheautumnof2015.Italsoprovidesadescriptionof thecontentanddiscussespossibleimplicationsofthereformforpatients,providersand governmentbodies.Insum,thereformcontainselementsofbothcontinuityandchange.

Themainnoveltyofthereformliesintheincreasedroleofprivatefor-profithealthcare providers.

©2016TheAuthors.PublishedbyElsevierIrelandLtd.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Institutionalsettingandreformbackground

AsinmostEuropeancountries,statutorycoveragein Norwayisobligatoryandoptingoutisnotpermitted.There isnochoiceofthestatutorybenefitspackagebutpatients areallowedtochoosetheirhealthcareprovider.Healthcare provisionisorganizedattwomainlevels,municipalities andstate.Themunicipalitiesareresponsibleforprimary careandenjoyagreatdealoffreedominorganizinghealth services.Patientsareingeneralfreetochoosetheirgen- eralpractitioner(GP).GPsactasgatekeepersresponsible forreferringpatientstospecialistcare,i.e.,aprivatelyprac- ticingspecialistorahospital.Thereferralprocessnormally comprisesthefollowingstages:(1)theGPexaminesthe patientand,ifspecialistcareisneeded,writesaletterof referral;(2)thereferralisassessedbyapublichospital;(3)

∗ Correspondingauthor.Tel.:+4793257161.

E-mailaddress:[email protected](Å.Ringard).

thehospitaldeterminesifcareisneededandifthedeci- sionisaffirmativethehospitalgrantsthepatienttheright totreatmentwithinaspecifiedperiodoftime(waitingtime guarantee);(4)iftheguaranteedwaitingtimeisexceeded bythehospital,thepatientisallowedtoselectanalter- nativeprovider(eitheranotherpublichospitaloraprivate hospitalundercontractwiththeRegionalHealthAuthor- ity(RHA))[1].Theresponsibilityforspecialistcarelieswith thestate—theownerofthefourRHAs,whichinturnown hospitaltrusts.TheMinistryofHealthinfluencestheactiv- ityoftheRHAs(e.g.,whattheirbudgetallocationshouldbe spenton)throughitsannual“lettersofinstruction”.These lettersaresupplementedbyannualcircular lettersfrom theDirectorateofHealthfocusingonissuessuchasquality ofcare,e-health,etc.TheDirectorateisanagencysubordi- natetotheMinistryandisinvolvedinimplementationof healthcarepolicies.

Waitingtimesforelectivehospitalcarehavebeenseen asamajorshortcomingofthehealthcaresystemsincemid- 1980sandhavebeenthemotivationbehindanumberof

http://dx.doi.org/10.1016/j.healthpol.2016.02.013

0168-8510/© 2016 The Authors. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

waiting-timeguarantees andchoicereforms[1,2].Since 2001,somaticpatientshavehadtherighttochooseany publichospitalinthecountry(butthelevel ofhospital, secondary or tertiary, couldnot be chosen)[3]. Subse- quently,patientchoicewasexpandedtoincludeprivate hospitalscontractedbytheRHAs(patientswhoreceived careatprivatehospitalsnotcontractedbytheRHAshad topayforitoutoftheirpocket).However,thisexpansion didnotnecessarilymeanamajorchangeforthepatients in terms of increasing theirchoice asalmost all hospi- tals inNorway (approximately99%)arepublicly owned andfundedthroughpublicbudgets[4].Not-for-profitpri- vatehospitals,oftenorganizedasfoundationsownedby ideologicalorganizationssuchasthechurch,arepublicly fundedandseenaspartofthepublichealthcareservices.

Privatefor-profit(PFP)providersplayasmallroleinthe provisionofspecialistcare,aslessthan1%ofhospitalbeds areinprivatefor-profithospitals[1].Thelargestproportion ofprivateprovisionofsomatichospitalcareisfoundfor electivedaysurgery(about10%)[5].Otherpatientanduser groups,suchaspsychiatricpatientsandpatientsinneed oftreatmentforalcoholandsubstanceusehavealsobeen grantedtherighttochooseahospital/institution(in2004 and2005,respectively).Inrecentyears,theRHAshavealso startedofferingpatientstheoptiontoreceiverehabilitation careinadifferentregion.

Although patient choice can contribute to reducing hospital-waiting times for individual patients [6,7], an overall effectonwaiting timesinNorway hasyettobe demonstrated. Thewaiting timesproblemhaspersisted andnotleftthepolicydebate.Accordingtoa2010OECD survey,21% ofNorwegianrespondentshad towaitfour monthsormoreforelectivesurgery(thirdhighestscore afterCanada(25%)andSweden(22%))[8,9].Between2011 and2014,theaveragewaitingtimeswerethehighestfor somatictreatment(70 and80 days),withpatientwait- ingfororthopaedicandmedicallyessentialplasticsurgery facingthelongestwaitingtimes.Foralcoholanddrugtreat- ment a reduction in waiting times wasobserved, from about75daysin2011toabout60daysin2014.Forpsy- chiatriccare,theaveragewaitingtimesremainedstableat about55days[10].

Thearticleaimstodescribethebackgroundandpro- cessleadinguptointroductionofthenewtreatmentchoice reforminlate2015.Itprovidesadescriptionofitscontent anddiscussespossibleimplicationsofthereformforthe patients,providersandotherstakeholders.

2. Policygoalsandpolicyprocess 2.1. Policydevelopment

Inmid-June2014,thegovernmentlaunchedwhatthey named the “reformof free treatmentchoice inspecial- istcare”[11].Theissueappearedonthepoliticalagenda priortotheGeneralElectioninSeptember2013,withthe Conservative Party campaigning in favour of extending patients’ choiceof hospital.TheConservativePartywon the2013electionsandwentontoformagovernmental coalitionwiththeProgressParty.Thetwopartiesaresup- portedbythecentristChristianDemocraticPartyandthe

LiberalPartyinParliament.Withrespecttohealthcare,the coalitionpartiesagreedthat“The Governmentwill(...) carryouta majorreformofthehealth service.Patients’

rightswillbestrengthenedandindividualswillbegiventhe righttochoosetheirhealthcareprovider.Thiswillensure thatpatientswillnothavetowaitinqueueswhenprivate andnon-profithealthcareprovidershaveavailablecapac- ity”[12].Thus, theprimaryfocus ofthereform wason strengtheningpatients’rightsbyincreasingtheirchoiceof healthcareprovider,withshorterwaitingtimesforelec- tivecarebeingthemoreimmediategoal.Privateproviders withouta tenderagreement withtheRHAswere tobe includedinthis extended choice,increasingthepoolof providersthatpatientscanchoosefrom.

ImmediatelyaftertheGeneralElectionsinSeptember 2013 the Ministry of Health and Care Services began draftingaproposalfortheannouncedreform.ThePrime Minister officially presented the draft proposal in June 2014, emphasizing once again that the reform was intendedtoextendtheexistingchoiceschemeandreduce waiting times for elective hospital care. The proposed reformwouldentailamendingseveralexistingpolicytools, includingpaymentmechanismsandICT-systems.Thepro- posalalsocalledfornewregulationsinthefollowingareas:

asystemofgrantingapprovalsforprivatehospitalstobe includedinthetreatmentchoiceschemewouldbeestab- lished(butitwasnotdetailedintheproposal)andanew systemforqualityassurancewouldbesetup,givingthe RHAstheresponsibilityforassuringqualityamongprivate hospitalsincludedinthescheme[11].

2.2. Thepublicconsultationprocessandkeystakeholder positions

Aftertheproposalwaspresented,theMinistryopened thecustomarypublicconsultationprocesstoprovidean opportunityforaffectedstakeholderstostatetheiropin- ions.The consultation process lasted three monthsand elicitedabout100responses[13].Fig.1summarizesthe positionofkeystakeholders.

Severalof thelargest patientorganizations (e.g.,the FederationofOrganizationsofDisabledPeople,theCan- cerSociety and thePatientOrganizationfor Circulatory Diseases)expressedconcernsabouttheproposal.Thekey reasonswere:complexityofthereformanditsadminis- trativecostsandtheopportunityforprivatehospitalsto prioritizetopatientswithmore“easy-to-treat”conditions.

Anotherissuewastheimplicationsforworkforceplanning inthepublicpartofthesystem,giventhatmoreprivate providerswould compete for thesame experts.Patient representativesfromthepublichospitalboardswerealso worriedthatprivatehospitalswouldprioritize“easy-to- treat”patientsandsuggested,inacommonstatement,that noprivatehospitalsshouldbegrantedtherighttoassess GPreferralsandtograntindividualpatientstherightto specialistcare.TheUnionforseniorcitizensexpresseda generalconcernabouttheongoingcentralizationofspe- cialistcare,andfearedthatthechoiceavailabletoolder couldberestrictedpatientsduetolongertraveldistancesto hospitals.However,theirpositionandthepositionofother patientgroupsweremorenuancedandsomeaspectsofthe

1

2 3

4

The Norwegian Medical Association

Patient organizations

Regional Health Authorities and Hospital Trusts

Private hospitals

The Norwegian Nurse Organization 5

very supporve

INFLUENCE

none strong

1

2 4

5

3 very unsupporve

POSITION

Fig.1. Stakeholderspositiontowardstheproposedchoicereform.Source:Authors’evaluations.

reformwereassessedpositively:patientrepresentatives fromthepublichospitalboardswelcomedthefactthatthe reformwouldremovethedivisionbetweenpatientswho couldaffordtoaccessprivatecareandthosewhocouldnot.

TheUnionforseniorcitizensalsosupportedtheopening ofthemarkettomoreprivateproviders,astheybelieved ittoimproveoverallaccesstocare.Organizationswithin thefieldsofmentalhealthandsubstanceusewereingen- eralmoresupportiveoftheproposal,butemphasizedthe needforthesimultaneousdevelopmentofdecisionmaking supportsystems.

TheSouth-EasternRHA(the biggestRHAin termsof populationandnumberofhospitals)wasscepticalabout theintroduction of a new quality regime linkedto the approvalofprivatehospitalsandthechangesinthefinan- cingmechanisms.TheRHAforesawtwodifferentquality regimesandseveralfinancingmechanisms.Thepositionof otherRHAswasinlinewiththatoftheSouth-EasternRHA.

ThelocalhospitaltrustssupportedtheirrespectiveRHAs, addingthatarapidincreaseofprivatehospitalscouldlead tostaffshortageinthepublicsector.

TheNorwegianNursesOrganisation(NNO)wasscepti- calabouttheincreasedroleofprivatefor-profitproviders.

TheNNOwasunconvincedthattheimpactofthereform onpublichospitalsandmunicipalitieshadbeensufficiently analysed.Morespecifically,theywereconcernedwhether itwouldbepossibletoassureprovisionofwell-coordinated carewhenpatientpathwayswouldbepartlytransferredto privateproviders.Theyalsofearedstaffshortageinpublic hospitals.

Unsurprisingly,the proposal was supported by PFP- hospitals,asitwouldpotentiallygivethemaccesstomore publicfundingaswellasamoreimportantroleinthepro- visionofspecialistcare.Theywereinfavourofhavinga centralqualityassurancesystemapplicabletoallhospitals, whichwouldensurethatthesamequalitystandardsapply toallproviders.Atthesametime,theyexpressedconcerns aboutwhethertheproposedschemewouldbesufficiently funded toencourage theestablishmentof more private hospitals.Contrary totheNNO, theNorwegian Medical

AssociationwasinfavourofallowingmorePFPproviders asameasuretoimproveaccesstospecialistcare.

2.3. Thepoliticaldebateandtheadoptionofthereform

Despite the concerns expressed in the consultation process,inJanuary2015thegovernmentdecidedtoput forwardthelargelyunchangedproposaltotheParliament [13,14].TheParliamentdebateditbetweenJanuaryand late March.Thevoting onthelegislativecomponentsof thereform, i.e.,the amendmentsof thePatients’Rights ActandtheSpecialistHealth ServicesAct,tookplacein mid-April.Asexpected,theoppositionvotedagainstthe proposalandthecoalitionparties,whohavethemajority of seatsintheParliament,voted infavour.Theamend- mentswereapprovedbytheParliamentattheendofMay andtheirimplementationwasscheduledfrom1November 2015[15].

3. Reformcontentanditsimplications

Thepatienttreatmentchoicereformrepresentsbotha continuationandchangewithrespecttopreviouschoice reforms(seeTable1).

Fromthepatients’perspective,themainchangeisthat thechoiceofhospitalproviderisgreaterthanbefore,asit nowalsoincludesnon-contractedprivateproviders.The fact that selected privatehospitalsare able toconsider GP referrals and grant the right to specialist care may meanfasteraccesstocareforpatients.Thereformisnot expectedtoimpactuponpatients’rightsobtainedthrough the recentlyimplemented EU Directiveoncross-border healthcare[14].

Previousrestrictionsontheannualnumberofpatients tobetreatedbypublichospitalshavebeenlifted,which mayimproveaccess.Althoughnotapartofthefreetreat- mentchoicereform,this changeisexpectedtoimprove thepositionofpublichospitalswhenthechoicereformis implemented[14].Patientchoice,however,didnotapply toprivaterehabilitationinstitutions.Afterthepassingof

Table1

The2015treatmentchoicereform:whathaschanged?

Stakeholders Situationpre-2015reform Changesintroducedby2015reform

Patients^a HavearighttochoosethehospitaltowhichtheirGP referralforspecialistcarewillbesenttoand considered–choiceamongpublichospitalsonly

Choiceextendedtocertainprivatehospitalswitha tenderagreementwiththeRHAs(detailsarebeing elaborated)

Patientswhoweregrantedtherighttospecialistcarehave achoiceofhospitalprovideramongpublichospitalsand privatehospitalsundercontractwiththeRHAs(somatic care,mentalhealthcareandaddictiontreatmentare included)

Choiceofhospitalproviderextendedtoallprivate hospitals,includingthosewithnocontractwiththe RHAs

Rehabilitationcareisnotexplicitlymentionedinthe scheme

Privaterehabilitationinstitutionsexplicitlynot included,butthegovernmenthasnowputforwarda newproposalthatincludesrehabilitationcarein thescheme

Publichospitals^b Included;havetherighttoassesGPreferralsandtogrant patientsrighttospecialistcare

Sameasbefore;butnofixednumberofpatientsthat canbetreated^c

Privateprovidersunder contractwiththepublic system

IncludedbutdonothavetherighttoconsiderGP referralsandgrantpatientstherighttospecialistcare (onlypublichospitalshavethisrightnow)

Sameasbefore;Selectedprivateproviderswitha tenderagreementwiththeRHAsmaybegiven permissiontoconsiderGPreferralsandgrant patientstherighttospecialistcare.

Privateprovidersnotunder contractwiththepublic system

Notincludedinthehospitalchoice Includedinthetreatmentchoice

RHAs^d Arrangetendersandcontractwithprivateproviders;

monitorprovisionofcontractedcare

Sameasbefore;Selectprivateproviderswitha tenderagreementthatcanconsiderGP-referrals andgrantpatientstherighttospecialistcare Expectedtopurchasemoreservicesfromprivate hospitalsthroughpublictenders^c

DirectorateofHealth Collects,processesandpresentsupdatedandrelevant informationtosupportpatientswhowanttoexercisetheir righttochoose(e.g.,throughwebsites,adedicated telephoneline)

Sameasbefore;Plusgrantsauthorizationtoprivate hospitalsnotundercontractwiththepublicsystem andsupervisesthem;determinesthetypesof servicesandpricesthatcanbeprovidedbyprivate non-contractedhospitalsandpaysthem

aRegulatedbythePatientRightsAct.

bRegulatedbytheSpecialistHealthServicesActandfuturesecondarylegislation.

cNotpartofthechoicereform(previouslyimplementedreforms).

dRegulatedbytheHealthAuthoritiesandHealthTrustsAct.

the legislation, thegovernment hasputforward a new proposalthat,whenenacted,willincludeprivaterehabili- tationinthechoicescheme.

Therightgiventocertainprivateproviderswithaten- deragreementwiththeRHAstoassessGPreferralsand tograntpatientstherighttospecialistcareimplychanges fortheRHAs.TheRHAswillhavetoestablishprocedures forgranting(andwithdrawing)permissionstoconsiderGP referralsbyprivatehospitalsand formonitoringprivate providersthathavebeengrantedthisright.TheRHAsare alsoexpectedtobuymoreservicesfromprivateproviders viapublictenders.Thisinturnmayconstituteadministra- tivechallengetotheplanning,budgetingandmonitoring processesoftheRHAs.

For PFP hospitals contracted by theRHAs, the main changeisthatinthefuturetheymaybegiventhesame rightaspublichospitaltograntpatientstherighttospe- cialistcare.Thischangewould,whenimplemented,give these providersthe same control over patient flows as thepublichospitalshavetodaywhenitcomestoreceiv- ingand assessingGPreferrals.Moreover,theymayalso begiven theauthority togrant thepatient therightto specialistcareandtosetindividualwaitingtimesforthe patients.

Forthenon-contractedPFPhospitalsthekeychangeis theirinclusioninthetreatmentchoicescheme.Inorderto beincluded,theseprovidersmustobtaina licencefrom the Directorateof Health. Among the prerequisites are theexistenceofinternalqualityassurance,communication (withmunicipalities) and electronicpatientinformation systems. The government has, to cover the expected increaseinactivity,grantedanaddition150millionNOK in2015and400millionNOKin2016.

Non-contractedPFPhospitalsmayonlyprovidehealth- care services that are included on a pre-defined list (togetherwiththeirrespectiveprices)setbytheDirec- torateofHealth.Thislistisbasedontheinformationabout bottlenecksinthepublicsystem(i.e.,longwaitingtimes).

Presently,thelistonlycontains inpatientservicesinthe areaofmentalhealthandsubstanceabusetreatmentand alimitednumberofserviceswithinsomaticcare.Private hospitalsarereimbursedonafee-for-service(FFS)basisby theHealthEconomicsAdministration(HELFO)[16](see[1]

formoreinformationabouttheroleofHELFO).TheDirec- toratewillalsohavetoensurethatprivatenon-contracted providerssatisfythesamestandardsforqualityofcareand patientsafetyaspublicandprivatecontractedproviders.

As before, the Directorate is responsible for collecting,

processingandpresentingupdatedandrelevantinforma- tion(e.g.,onwaitingtimes)tosupportpatientswhowant toexercisetheirrighttochoose.

4. Discussion

For many years, lengthy waiting times have been a seriousproblemintheNorwegianhealthcaresystemand persistedinspiteoftheimplementationofanumberof reformsaimedatreducingthem.Thenewtreatmentchoice reform wasproposedin June 2014 [11]. Thelegislative frameworkwasadoptedbytheParliamentinthespringof 2015andisnowbeingimplemented[15].Whileprevious reformsfocusedprimarilyonthepatients’righttochoose provider,lessattentionhasbeenpaidtodeveloping the supplysideofthesystem.The2015reformhas,although thereformrhetorichasfocusedonpatentchoice,mainly soughttodevelopthesupplysideofthesystem.Firstby includingprivatenon-contractedprovidersintothechoice schemeandsecondlytopavethewayforamoreenhanced roleforprivateprovidersundercontractwiththeRHAs.

Thedraftproposedtofirstextendthechoiceoftreat- ment totwo vulnerablepatients groups:mental health patientsandpatientswithsubstanceabuseproblems.Pri- vateprovisioniswellestablishedinthesetwoareaswhich may facilitate the establishment and inclusion of new providersinthescheme.Thegovernmenthasalsomadeit clearthattheRHAswillinthefuturebeexpectedtobuy moreservices fromprivatecontracted providers,which mayprovetobefurtherincentivefor newprovidersto enterthemarket.

Importantaspectsofthereformarestillbeingimple- mented.ThekeyquestionistowhatextenttheRHAswill transfertheresponsibilityofreceivingandassessing GP referralstoprivateproviders.Thequestioniscrucialfor thepublicsystem(theRHAs)intermsofbothcontrolling patients’flowsintospecialistcare,andforhavingcontrol overtheirownbudgets. Similarly,theDirectorateneeds to implement the structure and processes for approv- ingprivatenon-contractedprovidersandtomonitortheir activity.

The2015reformcanbedescribedascombiningexisting demandsidewithnewsupplysidepolicies,asitincludes both enhancingpatientchoiceand increasingsupply of bothpublicandprivatehospitalservices.Policiescombin- ingdemandandsupplymeasureshaveusuallybeenfound tohaveastrongereffectonreducingwaiting-timescom- paredtoinitiativesfocusingprimarilyoneitherdemand orsupplysidemeasures[17].Thus,othercountries(e.g., withintheOECD)strugglingwithlengthywaitingtimes may follow the developments in Norway with interest [18].

5. Conclusion

In terms of theimpact on health system goals, like access,itistooearlytospeculatewhattheoutcomesofthe reformmaybe.Thesuccessofthereformindrivingdown waitingtimeswilldependtoa largeextentonwhether patientswillactivelyexercisetheirincreasedopportunity tochoose. While prior tothe 2001reform Norwegians

were in general supportive of introducing choice of hospitalprovider[19],onlyafewpatientsactuallyexer- cised theirrightwhen seekinghospital care[7,20].The governmenthas,however,promisedtomonitorthereform.

Anevaluation, whichwillbeadministratedby theNor- wegian Research Council, is expected to start in 2016 [14].

Conflictofinterest

The authors declare that there are no conflicts of interest.

Acknowledgement

The authors would like to thank director Eamonn NoonanofTheInternationalSecretariatoftheCampbell Collaboration for providing valuable comments of the manuscript.

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