Competition versus gatekeeping in a listpatient system: A study of general practitioners’ prescription pattern for patients aged 70 and older

Presenter: Inger Carhine Kann, Akershus University hospital

Abstract

In the prevailing organisation of general practice in Norway, inhabitants are registered with a GP and the GPs are paid partly by capitation and partly by fee-for-service. Empirical evidence shows that this organisational model causes competition among GPs both in order to attract new persons to the list and to keep persons already registered on the list. The present study related to reimbursement drugs and addictive drugs are based on register data from the Norwegian Prescription Database (NorPD), merged with data from the regular general practitioner database (NSD). Our main research question is whether competition for patients boosts the number of prescriptions, which both undermine the gatekeeping role of GPs and may put patients’ health at risk. In a panel data model, taking observed heterogeneity like gender and age into account, we estimate the effects of observable variables on prescription. We also take unobserved heterogeneity into account; paying attention to the fact that patient will choose a GP who fits his or her preferences. Hence, the composition of patients may be endogenous. In contrast with previous research our data makes us able to distinguish between prescriptions (service provision) to persons registered on the GP’s list (internal patients), and prescriptions to other patients (external patients). We show that not taking the distinction of external and internal patients into account may lead to overestimation of the effect of competition on service provision. Our results indicate that GPs practicing in municipalities with high competition among GPs prescribe more drugs compared to their colleagues practicing in low GP competition areas. We conclude that in a list patient system with capitation payment, the prescription style contributes to attract patients to the GP. Hence, their prescription style conflicts with their role as gatekeepers to services paid for by national insurance. But even worse: their prescription might be a hazard to patients’ health.