Suchergebnisse

The thesis consists of an introductory chapter and three essays, considering sickness insurance, social norms and absence certification. The first essay, Group-Specific Social Norms and Economic Incentives in a General Welfare System, investigates the interaction between economic incentives and social influences in a general welfare system. We relate the results to sickness insurance. The model in Lindbeck, Nyberg & Weibull (1999) is modified by dividing the population into two groups, which are governed by group-specific social work norms. The behaviour of the two groups is studied in separate welfare systems as well as a shared system. We find that group affiliation matters for the generosity of the welfare policy, in terms of tax rate and transfer level, and for the share of transfer recipients. Furthermore, in a first-best scenario, it is observed that a restriction on the recipient share in exchange for a generous transfer may be optimal. Regarding the social norm, we find an ambiguous effect on the optimal welfare policy in a first-best scenario, whereas it implies a transfer increase in a second-best scenario. In the second essay, Sickness Absence Certification, we model sickness absence certification by assuming that the physician may certify absence for a worker without verifying that his ability to work is impaired due to sickness. Physicians with ?strict? as well as ?lax? sick-listing routines interact with workers who differ in their motivation for work. Depending on the physician type, or types, available and the expectations thereof, ?less motivated? workers are sick-listed regardless of working ability, while ?motivated? workers are sick-listed conditional on the observation of health-related ability impairment. We consider various policy instruments that the insurer may employ against a perceived misuse of the insurance and discuss their welfare implications, taking into account the match between worker and physician as well as the match between labour activity and working ability. The third essay, Occupational Physicians and General Practitioners ? Implications for Sickness Absence Certification, compares the certification practices of the occupational physician with those of the general practitioner. Whereas the latter adjusts his practices to the preferences of the worker, the former may have a restrictive attitude towards sick-listing, due to the client?s, that is the firm?s, influence. In contrast to the occupational physician's assessment of working ability, the general practitioner's assessment is imprecise, which implies an over-certification of sick-leave claims. Both ?less motivated? and ?motivated? workers prefer physicians with adjustable practices, resulting in different treatments of the workers regarding absence certification, provided that workers are able to attach expectations about treatment to individual physicians. However, ?motivated? workers also prefer correct information about ability, implying a risk of ?involuntary? sickness absence when general practitioners certify absence.

Several empirical papers have studied the effect of government size, typically measured as government expenditures, on economic growth. There is no consensus on the direction of this impact, even though more recent studies tend to find a negative relationship between the general level of government expenditures and economic growth. This negative relationship is explained by the distortions that raising tax revenues cause on economic activities. There are, however, several ways to raise tax revenues that likely have different distortionary effects and, hence, may impact economic growth differently. This paper analyses how taxation of income influences economic growth. More precisely we study how statutory tax rates on corporate and personal income affect economic growth by using panel data from 1975 till 2010 for 25 rich OECD countries. We find that both taxation of corporate and personal income negatively influence economic growth. The correlation between corporate income taxation and economic growth is more robust, however.

Abstract
The case for competition in health-care markets rests on economic models in which providers seek to maximize profits. However, little is known regarding how public health-care providers, who might not have a profit motive, react to increased competition from private providers. This study considers the heterogeneous effects of a primary health-care reform in a Swedish region that considerably loosened entry restrictions and increased patients' freedom of choice, thus enabling increased competition. Our difference-in-differences analysis contrasts local markets that were affected by both entry and choice with local monopoly markets, which were unaffected by the reforms. Using detailed administrative data on all visits to public health centers in 2008–2011, we find that providers in markets with increasing competition registered more diagnoses in an administrative database, thus increasing their reimbursement per patient. Although the economic significance of the effect is small, the result suggests that public providers are indeed sensitive to competition.

OBJECTIVE: The objective was to examine the association between primary care consultations and a Care Need Index (CNI) used to compensate Swedish primary care practices for the extra workload associated with patients with low socioeconomic status. DESIGN: Observational study combining graphical analysis with linear regressions of cross-sectional administrative practice-level data. SETTING: Three Swedish regions, Västra Götaland, Skåne and Östergötland (3.5 million residents). Outcomes were measured in February 2018 and the CNI was computed based on data for 31 December 2017. SUBJECTS: The unit of analysis was the primary care practice (n = 390). MAIN OUTCOME MEASURES: i) Number of GP visits per registered patient; ii) Number of nurse visits per registered patient; iii) Number of morbidity-weighted GP visits per registered patient; iv) Number of morbidity-weighted nurse visits per registered patient. RESULTS: The linear associations between the CNI and GP visits per patient were positive and statistically significant (p<0.01) for both the unweighted and weighted measure in two regions, but the associations were mainly due to 10 practices with very high CNI values. The results for nurse visits varied across regions. CONCLUSIONS: For most levels of the CNI, there was no association with the number of consultations provided. This result may indicate insufficient compensation, weak incentives to spend the money, decisions to spend the money on other things than consultations, or stronger competition for patients among low-CNI practices. The result of this observational study should not be taken as evidence against the possibility that the CNI adjustment of capitation may have affected the socioeconomic equity in GP and nurse visits. Key Points Swedish primary care practices receive extra compensation for socioeconomically deprived patients but it is unknown how this affects service provision. Practice-level data from three regions years 2017-2018 indicate weak or no relation between the socioeconomic burden and the number of physical consultations per patient. Results are similar when adjusting for patients' morbidity levels, suggesting that the weak gradient was not explained by longer consultations. The exception is that a small number of practices with very high burdens provide more consultations per patient. The results may reflect insufficient compensation, lack of incentives, or funds being spent on other things than consultations.

AbstractReducing socioeconomic health inequalities is a key goal of most health systems. A challenge in this regard is that healthcare providers may have incentives to avoid or undertreat patients who are relatively costly to treat. Due to the socioeconomic gradient in health, individuals with low socioeconomic status (SES) are especially likely to be negatively affected by such attempts. To counter these incentives, payments are often risk adjusted based on patient characteristics. However, empirical evidence is lacking on how, or if, risk adjustment affects care utilization. We examine if a novel risk adjustment model in primary care affected socioeconomic differences in care utilization among individuals with a chronic condition. The new risk adjustment model implied that the capitation—the monthly reimbursement paid by the health authority to care providers for each enrolled patient—increased substantially for chronically ill low‐SES patients. Yet, we do not find any robust evidence that their access to primary care improved relative to patients with high SES, and we find no effects on adverse health events (hospitalizations). These results suggest that the new risk adjustment model did not reduce existing health inequalities, indicating the need for more targeted incentives and interventions to reach low‐SES groups.

The Swedish Social Insurance Agency is an important part of the Swedish welfare state. The Agency has recently made a number of major changes, such as establishing a new internal organization and reforming processes for decision making. Many of these changes have been controversial. Critics have complained that the Agency shows a lack of efficiency, has failed to make payments on time, and has been too harsh in its application of eligibility rules. The changes have put the agency at a number of crossroads, many of them recurring from earlier reforms, in dealing with problems such as regional differences in the application of rules. In this article, some of these choices are discussed. The discussion departs from four dichotomies: uniformity-local adaptation; centralization-decentralization; specialization-generalist approaches; and closeness-distance. These dichotomies are illustrated with examples from the agency. The general conclusion is that although the change process has taken a rocky road, there has been a great deal of internal consistency in the combination of measures taken.