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Physician Dual Practice and Shortages of Providers

Country: 
Denmark
Partner Institute: 
University of Southern Denmark, Odense
Survey no: 
(15) 2010
Author(s): 
Karolina Socha
Health Policy Issues: 
HR Training/Capacities
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Abstract

The authorities of the Capital Region of Denmark attempted to make dual practice of public hospital physicians subject to the public employer?s consent. It was argued that dual practice resulted in shortages of physicians? labour because physicians who hold an extra job in a private hospital work less hours in the public sector and in total than physicians who provide labour exclusively to the public sector. Such a regulation was in conflict with labour agreements and had to be abandoned.

Purpose of health policy or idea

Physician dual practice is a notion used to describe a situation when a physician holds simultaneously a job in a public and in a private hospital. It has been observed in Denmark that physicians earn more per hour in private hospitals than in public hospitals. Thus, there has been the fear that physicians engaged in dual practice (dual practitioners) might cut down working hours in a public hospital, i.e. work only part-time or avoid overtime work, in order to spend more working hours at the private hospital. Moreover, dual practitioners might cut down on total working hours. The reason is that the decrease in work hours supplied to the public hospital might not be balanced by an increase in work hours supplied to the private hospital because dual practitioners can compensate for shorter total working hours with higher hourly earnings from the private sector. Consequently, dual practice might intensify the problem of physician shortages, especially in the public hospital sector. In order to address the matter, the authorities of Region Capital attempted to control dual practice prevalence among physicians employed in the region's public hospitals by making the right to engage in dual practice subject to a consent of a public employer. The idea, if implemented, would directly affect physicians employed at the region's public hospitals whose freedom to take up an extra job in the private health care sector would be constrained. So far, physicians employed at public hospitals have been obliged only to inform their employer about engagement in dual practice.

Main points

Main objectives

The main objective of the policy idea was to control the prevalence of dual practice among public hospital physicians through an introduction of a legal instrument constraining the physicians' freedom to engage in dual practice. 

Type of incentives

The policy idea did not involve any financial incentives.

Groups affected

Physicians employed in public hospitals

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

The policy idea did not result from a change in Government - there was no national or regional change in Government - or need to comply with certain regulations or a health policy program.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Origins of health policy idea

Hospital care in Denmark is a responsibility of the regional governments. During the last few years, the president of the organisation of Danish Regions has voiced fears about negative effects of physician dual practice on among others, physicians' labour supply. Physician shortages have been a growing problem in Denmark and the prognosis until 2025 predicts that the problem will become more prevailing (National Board of Health). Physician dual practice has attracted a particular attention after the 2002 health law amendment introducing the extended free choice of a hospital, which allows public patients to chose a free treatment in a private hospital if the public hospitals are not able to offer the treatment within the guaranteed maximum waiting time (one month from 2007 on; two months in 2002-2007). The rule of the extended free choice of a hospital boosted growth of the private hospital sector and produced opportunities for physicians to engage in dual practice. At the same time, the extended free choice rule provided the regional governments with an incentive to increase the public hospitals' activity in order to fulfil the maximum waiting time guarantee. In such context, the representatives of the regions have voiced fears that dual practice hampers the public hospitals' ability to increase the activity rates and might also effect in a decrease of the total activity in the hospital sector. The policy idea proposed in January 2010 by the president of the Capital Region has been the first concrete attempt towards establishing a control over dual practice prevalence.

Initiators of idea/main actors

  • Government: The idea was initiated by the authorities of Region Capital. However, intentions to introduce a control over dual practice prevalance have been voiced by the President of the organisation of Danish Regions several times during the last few years.
  • Providers: Providers, understood as physicians employed in the public hospital sector, have been in strong opposition towards proposals of measures constraining the possibilities to engage in dual practice.

Stakeholder positions

Providers, understood as physicians employed at the public hospitals have been in strong opposition towards the policy idea. The voice of the providers has been represented by the President of the Danish Medical Association (Overlægeforeningen) who evaluated the idea as being in conflict with the current agreement on employment conditions concluded between the representatives of the physicians and the Danish Regions in 2008. The Medical Association underlined that according to the agreement on employment conditions currently in force physicians have the right to engage in dual practice or in any other type of dual job holding and are only obliged to inform their employer about the engagement in dual practice or other dual job holding. The Medical Association stated that if the authorities of Region Capital continue with the implementation of the idea the Association will bring the case in front of a court of law. In consequence, in March 2010, on a negotiation meeting between the authorities of Region Capital and the Medical Association a decision was taken to abandon the idea.    

Actors and positions

Description of actors and their positions
Government
President of Capital Regionvery supportivevery supportive strongly opposed
President of the organisation of Danish Regionsvery supportivevery supportive strongly opposed
Providers
Danish Medical Associationvery supportivestrongly opposed strongly opposed

Influences in policy making and legislation

The policy idea was abandoned and will not lead to a formal piece of legislation. It is possible that the regional authorities will seek to incorporate such an idea in the next agreement on employment conditions between the regions and the Medical Association. (The current agreement will be in force at least until end of March 2011 and the official negotiations of a new agreement can start at the earliest three months before that date.) However, taking into account the strong difference of opinion on the subject between the two parties, the attempt might be again unsuccessful.     

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Government
President of Capital Regionvery strongstrong none
President of the organisation of Danish Regionsvery strongstrong none
Providers
Danish Medical Associationvery strongvery strong none
President of Capital Region, President of the organisation of Danish RegionsDanish Medical Association

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Concluding so far, it can be argued that, implementing a measure which constrains engagement in dual practice might actually intensify the problem of physician shortages. Dual practitioners provide extra hours of work to the hospital sector. If dual practice prevalence decreased, the number of hours of labour provided by the hospital physicians would also decrease. Consequently, satisfying the waiting time guarantee would become more difficult.

The argument that dual practice might result in or intensify the problem of physician shortages contains several assumptions which do not find support in the evidence on dual practice recently collected in Denmark. First, such argumentation includes a suggestion that dual practitioners tend to hold a part-time employment contract in the public hospital sector. Further, it suggests that dual practitioners avoid overtime work in the public hospitals more often than their counterparts who work exclusively in the public sector. Moreover, the fact that dual practitioners earn more per hour of work in a private hospital than in the public one might not necessarily lead to a decrease in hours of labour they are willing to supply. It is equally possible that higher hourly wage induces dual practitioners to work more hours in total compared to physicians who hold a single job.

In 2009, the University of Southern Denmark in cooperation with the Danish Medical Association distributed an on-line questionnaire among hospital physicians to collect data on dual practice in Denmark. The questionnaire was answered by more than 5000 public hospital physicians. It is so far the largest empirical study into the prevalence of dual practice. The analysis of the data revealed that 94 percent of the dual practitioners worked full time in the public hospital with the mean and median working week of 44.7 and 42.5 hours respectively in 2008. Most importantly, dual practitioners did not differ from other full time working physicians with regard to average length of work week in public hospitals. Dual practitioners did not differ from other physicians also with regard to the average overtime per week, also in the hospitals where overtime was compensated with time-off instead of money. Moreover, the data does not indicate that the average length of work week in public hospitals decreases with the increase in the number of hours supplied to the private health care sector. To the contrary, these physicians who work long hours in the private sector tend also to work long hours in a public hospital. It should be also underlined that nearly 60 percent of dual practitioners reported that they had no possibility to increase the number of working hours in their public hospital beyond their actual work hours.   

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low very low very high

References

Sources of Information

  • Lægeprognose - Udbudet af læger 2000-2025. Sundhedsstyrelsen, 2003 (Prognosis for physicians' labour supply 2000-2025, National Board of Health)
  • Lægeprognose for udbuddet af læger i perioden 2004 - 2025. Sundhedsstyrelsen, 2006 (Prognosis for physicians' labour supply in the period 2004-2025, National Board of Health).
  • Dagens Medicin, 29th March 2010. Hovedstaden dropper at godkende lægers bijob.
  • Dagens Medicin, 19th March, 2010. Hovedstadens læger skal spørge om lov, hvis de vil bijobbe.  
  • Regionernes Lønnings-og Takstnævn. Aftale om oplysningspligt ved bibeskæ ftigelse 200.

Author/s and/or contributors to this survey

Karolina Socha

Research Assistant, The Research Unit for Health Economics, Institute of Public Health, University of Southern Denmark.  

Suggested citation for this online article

Karolina Socha. "Physician Dual Practice and Shortages of Providers". Health Policy Monitor, April 2010. Available at http://www.hpm.org/survey/dk/a15/3