Transcript Benchmarking of productivity in the Nordic countries

Benchmarking of productivity
in the Nordic countries
Jon Magnussen
Nordic Case Mix Conference
Helsinki 2010
Contributors
Denmark
– Kim Rose Olsen
– Anette Søberg Rød
– Jes Søgaard
– Anni Ankjær-Jensen
– Janni Kilsmark
Finland)
– Unto Häkkinen
– Miika Linna
– Mikko Peltola
– Timo Seppälä
– Kirsi Vitikainen
Norway
– Jon Magnussen
– Sverre Kittelsen
– Kjersti Hernæs
– Kjartan S Anthun
Sweden
– Clas Rehnberg
– Emma Medin
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
But: Differences in health policy
• Governance
• Financing and contracting
• Choice and rights
• There is a common model but we differ in
how we approach important issues
Decentralization
Nursing/
home care
Primary
health
Specialised
health
Finland
Municipality
Municipality
(Municipality)
Sweden
Municipality
Counties
Counties
Denmark
Municipality
Regions
Regions
Norway
Municipality
Municipality
Regions
Financing
• Sweden and Finland both use DRGs but
have local variations
– Finland mostly (?) for budgetary purposes
– Sweden partly for budgetary purpose, partly
for activity based financing
• Geographical resource allocation less of
an issue
Financing
• Norway have used DRGs in activity based
financing since 1997
• Denmark introduced DRGs as a marginal
payment in 1999, but have increased the
use to cover 50 % of income in 2007
• Centrally initiated uniform models for the
whole country
Norway ABF – an illustration
70
60
50
40
30
20
10
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20??
Our approach
• Productivity analysis on hospital level data
• Two separate analysis
– 1999-2004; Norwegian hospital reform
– 2005-2007; Specialised health care in Norway
• Data Envelopment Analysis (DEA) with Farrell
technical productivity
• Bootstrapping to test differences and estimate
confidence intervals
• Second stage analysis:
– Reform effects
– Financing models
– Structural factors
Data envelopment analysis
(DEA)
method
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a) Feasability
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x
b) Free Disposal
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c) Convexity
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x
d) Minimum
extrapolation
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Production model
• Outputs 1999-2004:
– DRG-weighted Inpatients in 3 groups
• Medical, Surgical, Others
– DRG-weighted Day care patients in 2 groups
• Medical, Surgical
– Number of Outpatients
• Outputs 2005-2007:
– DRG-weighted inpatients
– DRG-weighted day care
– Number of outpatients
Challenges
• Finland/Sweden – specialty discharge
rather than hospital discharge
• Denmark – DK-DRG
• Day care – and outpatient visits
Production model
• Inputs:
– Operating costs in real value
– Problems:
• Comparability of price level for hospital inputs, variation
across hospitals and remaining variation across countries
• Consistent removal of capital costs?
• Consistent removal of costs associated with research,
teaching, psychiatric care etc etc
• Aggregation problem
– Sweden and Norway cannot always use hospital level
data
– Scale interpretations are problematic,
Productivity/CRS model used
DRG-weights
• 1999-2004:
– Common Nordic weights as (weighted) average of
NO/Fin/Swe cost weights
• 2005-2007:
– Norwegian weights
– Aggregate weights for complicated/uncomplicated
– Separate (calibrated) Danish weights
• Ideally: Patient level data grouped – so far not
possible
Input price deflator (wages and GDP)
1.100
1.000
0.900
Danmark
0.800
Finland
Sverige
Norge
0.700
0.600
0.500
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Results 1999-2004
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
1999
2000
Danmark
Series5
Series9
2001
Sverige
Series6
Series10
2002
Finland
Series7
Series11
2003
2004
Norge
Series8
Series12
2nd stage
• Reform has increased productivity level by
approx 4 %
• Robust to different specifications
• And:
– Changes in Activity based financing (ABF) has no
effect (?)
– Changes in case-mix has no effect
– Length of stay (LOS) longer than expected (within
each DRG) is associated with lower productivity
(severity or inefficiency)
Results 2005-2007
90
80
70
60
50
40
30
20
10
0
2005
2006
Finland
Sweden
2007
Denmark
Norway
Salterdiagram
Second stage analysis
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Country
Year
Region
Teaching hospital
Case-mix index
Length of stay deviation
Share of outpatient activity
Size
Summary of results
• Significant higher levels of productivity in Finland
– Small differences between Norge, Sverige og
Danmark
– Large intra country variations
• Diseconomies of scale?
– Could be case-mix
– Careful interpretation because different definitions of
units
• Other explanatory variables – not significant
– Thus LOS deviation, no longer different
Speculation
• Same result in three different analyes of Norway
and Finland (1999, 1999-2004, 2005-2007)
• Same result in two analyses of Norway/Sweden
(1999-2004, 2005-2007)
• Why?
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Personnell mix?
Level of personnell
Capitalization?
Case-mix
Different institutional setting?
The way forward
• Using patient level data to provide a common
grouping of patients
• Harmonizing measurement of day care and
outpatient activity
• Cost weights – or possibly more disaggregated
analysis
• Micro level analysis to understand differences
• A larger dataset to be able to test second stage
variables