Vortragssitzung
Physician and LTC staff shortage
Talks
The Effects of LTC Staff Shortages on Hospital Length of Stay
Lea Bergmann, RWI - Leibniz Institute for Economic Research
Einleitung / Introduction
The scarcity of skilled workers poses a significant challenge in Germany. This issue is particularly pronounced in the healthcare sector. Since nursing homes are required to follow strict staffing regulations, nursing homes may not occupy all available beds if they cannot recruit sufficient personnel, which ultimately leads to a reduction of available nursing home beds. Therefore, some patients may not be discharged from hospitals to nursing homes, resulting in longer hospital stays. Given that hospital care in Germany is around six times more expensive than care provided in nursing homes, this extended length of stay (LOS) in hospitals translates to higher costs for the healthcare system. Moreover, patients affected by these delays may experience adverse effects on their physical mobility and mental well-being. In this study, we investigate the impact of the shortage of long-term care (LTC) staff on hospital LOS. Our contribution is threefold: First, we are the first to analyze the effect of LTC staff on hospital LOS. Second, we determine whether hospitals and LTC facilities can serve as short-term substitutes. Lastly, we provide empirical evidence on how the scarcity of LTC staff affects healthcare provision.
Methode / Method
We use a mixed hazards model to assess the effect of staff shortages in LTC facilities on hospital LOS for patients transferring to nursing homes. Our study is based on insurance claims data and county-level information from the LTC statistics in Germany between 2010 and 2019. We quantify staff shortage by computing the ratio of job vacancies for LTC staff relative to the total number of budgeted positions separately for registered nurses and nursing assistants to account for differences in skill mix. We exploit the regional variation in LTC staff to estimate the causal effect of LTC availability on hospital LOS.
Zusammenfassung / Conclusion
While we would assume that nursing shortage increases LOS, our preliminary results show no significant effect on hospital LOS for elderly patients requiring a nursing home bed after hospital discharge. One plausible explanation for the lack of impact may be that German hospitals possess a strong financial incentive to discharge patients. Hence, hospitals may opt to discharge patients to alternative settings including home care or rehabilitation facilities instead of waiting for nursing home availability. However, if these alternative settings cannot provide sufficient professional nursing care, the health of the patients might suffer. Our next steps will thus be to finalize our estimation, including robustness and heterogeneity analyses, and analyze how patients’ well-being is affected by the shortage of LTC staff to gain a better understanding of the consequences of the current nursing shortage.
Authors
Lea Bergmann, RWI - Leibniz Institute for Economic Research
Dörte Heger, RWI - Leibniz Institute for Economic Research
Christiane Wuckel, RWI - Leibniz Institute for Economic Research
Where does it hurt? Local general practitioner reductions and hospitalization risk in Germany
Barbara Stacherl, DIW Berlin
Einleitung / Introduction
Adequate access to primary care is a central goal of health systems globally. However, recruiting and retaining general practitioners (GPs) in outpatient care is getting increasingly challenging. Suboptimal access to primary care may lead patients to delay or avoid care which can result in more severe conditions requiring hospitalization. Such “avoidable hospitalizations” imply adverse effects both for patients – more severe health issues – and the health system – more costly hospital care. Therefore, it is vital to investigate the relationship between GP reductions and hospitalization risk.
Methode / Method
I used data from the German Socio-Economic Panel (SOEP), a representative longitudinal household survey combined with geodata on outpatient GPs in Germany for the study period 2010-2019. The outcome was the likelihood of being hospitalized in the previous year. The exposure was a reduction from one year to the next in GP density within a radius of 10km around an individual, capturing an individual-specific change in GP density. I exploited this variation in a difference-in-differences framework to assess the impact of GP density reduction on individual hospitalization risk. To pin down the GP density reduction required for observing changes in hospitalizations different thresholds capturing different treatment intensities were used to define treatment and control groups. Only individuals with a GP density equal or lower than the nationally defined GP density target ratio and only those who did not move between pre- and post-treatment years were included.
Ergebnisse / Results
Exclusion of movers, those with above-target GP density, and those with incomplete survey information, resulted in a sample of 30,234 observations across ten years. Looking at the effect of GP density reduction on hospitalization, no significant effects were found in any of the scenarios capturing different treatment intensity. That is, for none of the investigated thresholds of GP density reduction, an effect on hospitalizations was observed. This implies that the effect of GP density on hospitalizations reported in the literature could not be confirmed here.
Zusammenfassung / Conclusion
I don’t find drastic implications of empirically observed reductions in GP density for individual hospitalizations in the German context. This suggests that potentially avoidable hospitalizations are not (yet) resulting from GP supply reductions, possibly because overall levels of GP density are still relatively high in Germany. However, it might also be the case that individuals affected by GP density reductions simply substitute for specialist care or emergency department visits instead of primary care, implying efficiency concerns.
Authors
Barbara Stacherl, DIW Berlin
Discontinuity in Primary Care and its Effects on Healthcare Utilization – Evidence from Resigning German General Practitioners
Matthias Westphal, University of Hagen
Einleitung / Introduction
Closures of General Practitioner (GP) practices are an increasing problem in Germany. Generally, disruptions in the patient-provider relationship could, on the one hand, decrease the accessibility of primary care, the cornerstone of all health systems. On the other hand, the practice style of the exiting GPs could be old-fashioned so that patients could benefit in total. The existing literature has documented that a disruption in primary care induced by resigning GPs, has negative consequences for patients, on average. However, the question remains whether this is also true in the German setting, where patients are less restricted in choosing GPs. Moreover, by using rich administrative data from a large German statutory health insurer, we may have more statistical power compared to the existing literature to identify clear and meaningful effects.
Methode / Method
We combine the rich administrative panel data with event-study regressions to evaluate the disruptions for patients induced by resigning GPs. We probe the robustness of our results by leveraging the new two-way fixed effects estimators suggested by the literature.
Ergebnisse / Results
We first find that patients do not anticipate the exit of the GP until five quarters before. This is reassuring for assessing the causal effects in the periods thereafter. Here, we find that - Primary healthcare utilization is reduced, primarily through fewer contacts with GPs. - Patients seem to substitute care by GPs with primary care provided by specialists - Hospital costs increase, particularly for ambulatory case-sensitive conditions and emergency cases - Patients are more likely to be diagnosed with previously undiscovered chronic diseases after their GP resigns. This is probably due to inefficient primary care before. - The negative effects on demand for primary care are more pronounced for younger individuals, while older individuals drive the positive effects on hospital care.
Zusammenfassung / Conclusion
Our results demonstrate that the relationship between patients and their GP is essential for frictionless access to the healthcare sector. Compared to the literature, our results are more pronounced, which is remarkable given that patients are less restricted in choosing their healthcare providers.
Authors
Matthias Westphal, University of Hagen
Daniel Monsees, RWI Essen
Automatic Recognition and Labour Market Effects – Evidence from German Physicians
Jan Köhler, ZEW - Leibniz Centre for European Economic Research
Einleitung / Introduction
The shortage of physicians in Germany is a pressing issue. Several factors contribute to this shortage, including an increasing demand for medical care due to an aging population and a decreasing supply due to a growing number of retirements and a trend towards more flexible part-time working models. To address this problem, health policy aims to facilitate the integration of foreign physicians into the workforce through the automatic recognition of their qualifications. This was legally established at the European level in 2005 by Directive 2005/36/EC on the recognition of professional qualifications, and was implemented in German law in 2007. This paper examines whether the automatic recognition of foreign medical qualifications has led to an increase in the number of physicians from EU countries in Germany.
Methode / Method
We leverage the variation introduced by the 2005 EU Directive, which facilitated automatic recognition for physicians from EU countries, but left recognition requirements to physicians from non-EU countries unchanged. Methodologically, we use a Difference-in-Differences (DiD) and Event Study approach to estimate the effect of the automatic recognition of medical qualifications while controlling for general trends in health care. We use publicly available panel data aggregated from local State Medical Associations. It provides comprehensive information on the physician stock in Germany, disaggregated by year, country of origin, and medical specialty for the period from 1995 to 2019. To account for potential confounding factors, the dataset includes control variables related to GDP, employment, physicians per capita, and life expectancy, among others, obtained from the World Bank.
Ergebnisse / Results
For a treatment group of 13 countries that have been member states of the EU since 1995, we find an average increase of 214 foreign physicians working in Germany. We compare this to 125 non-EU countries, that are never-treated control countries. The effect of an increase in foreign EU physicians is particularly pronounced for the inpatient sector, where the reform leads to 163 additional foreign physicians on average. In the outpatient sector, an average of 26 additional physicians are now working in Germany. A DiD Event Study with country fixed effects and further controls indicates a continuous and significant increase in foreign physicians in the years after the reform.
Zusammenfassung / Conclusion
The physician shortage that poses a significant challenge to health care access in Germany could be alleviated by facilitating the inflow of foreign physicians to Germany. Our results show that the recognition of foreign qualifications is an effective policy instrument to increase health care supply.