Joar Røkke Fystro, Ph.D.-student at the University of Oslo, mapped out arguments for and against the non-attendance fee in public documents.
“The non-attendance fee was introduced to motivate patients to show up to or give notice that they cannot attend appointments in the health care services,” Joar Røkke Fystro says.
He is a Ph.D. student at the Department of Health Management and Health Economics at the University of Oslo, and first author of the study.
“The non-attendance fee has been increased many times the past years. From January 1, 2023, the fee is NOK 1,500, four times the usual user fee. That is a lot,” Fystro says.
“The exception is for mental health care services and substance abuse treatment where the patients pay a fee equivalent to the regular user fee of NOK 375,” he says.
In the study, the researchers analyzed arguments for and against the non-attendance fee in public consultation documents. “The non-attendance fee is important to do research on, because these types of schemes affect everyone, both patients who are better and worse off. The non-attendance fee is a big expense for many,” he says.
“Mapping out the arguments for and against patient non-attendance fees in health care: an analysis of public consultation documents” is published in the Journal of Medical Ethics.
The non-attendance fee was introduced in Norway in 2001, for outpatient specialist visits at public hospitals. From 2009, it was formally implemented for all health professionals.
The specialist health care services in Norway include all health care services not offered by the municipal health care services, for instance hospitals, institutions for substance abuse treatment, and psychiatric centers in the districts.
“The non-attendance fee was introduced to motivate patients to attend appointments in the health care services or to give notice in advance that they cannot attend. This is supposed to prevent long waiting times and poor utilization of resources,” Fystro explains. “Usually, other patients cannot step in and attend the appointments if someone does not show up. This causes health care professionals to become inactive. If the patients gave notice that they would not be able to attend in advance, the appointment could have been taken by someone else.”
In the study, the researchers analyzed public consultation documents from five different public consultations, held between 2009 and 2021. The consultations suggested changes and adjustments to the non-attendance fee.
Before changes to public laws or regulations, public consultations are held regarding the proposals. Then different organizations, institutions, ministries, directorates, and patients/individuals have the opportunity to comment on the proposal.
“In this study, we have analyzed 84 public consultation documents, submitted by various public organizations, patient- and user organizations, and trade unions,” Fystro says.
In the consultation documents, the researchers found many different arguments for and against the non-attendance fee. “There was broad agreement that it is a genuine problem that people do not show up for their appointments in the health care services, for the hospitals, patients, and society. Many supported the non-attendance fee as a financial incentive, used to reduce the number of patients who do not show up,” Fystro says.
The researchers found no arguments against the non-attendance fee before it was doubled.
“Perhaps this is because we are used to paying a user fee when we have an appointment in the health care services. We can speculate whether it feels more symmetrical to pay a non-attendance fee equivalent to the user fee,” Fystro says.
Several argued that there could be various reasons why patients do not attend their appointments in the health care services, which are not necessarily due to a lack of motivation to show.
“The fact that patients do not show up to their appointments can be due to reasons beyond the patients’ control,” Fystro says.
This can be reasons like acute illnesses, transport challenges, long travel distances to the hospitals, and cognitive challenges or illnesses which make it more difficult to attend.
“Some argued that the patients themselves choose not to show up. Others said some patients might not be aware of the consequences of not showing up for their appointments,” Fystro explains.
“Many were concerned about the social consequences of the non-attendance fee, and whether it was perceived as fair. They worried that the fee would affect vulnerable groups in society negatively,” Fystro says.
Several argued that the non-attendance fee hits harder for some, because they cannot afford to cover it. For patients with poor health or reduced functional capacity, it may be more difficult to show up for the appointments.
“Many were concerned that the non-attendance fee could lead to increased social inequalities in health in Norway. Some believed that the fee could threaten access to health care services, and lead to some not receiving treatment or attending their appointments, because they cannot afford to pay a possible fee,” Fystro says.
Several argued that the exemption scheme that applies to mental health care services and substance abuse treatment, also should apply to other patient groups.
“Some of the patients who receive treatment for drug abuse or mental health disorders for instance, have additional health issues, and need treatment within parts of the health care system where they have to pay a non-attendance fee if they do not attend their appointments,” he says.
“Several argued that if it was not a lack of motivation causing the patients to not show up for appointments in the health care services, the non-attendance fee would not have the desired effect,” Fystro says.
Many also did not believe that increasing the non-attendance fee more and more would have any effect on whether patients showed up for their appointments or not.
“Others argued that if the health services receive income from patients not showing up, they will not work to ensure that patients actually show up to their appointments,” Fystro explains. “Some were also worried that the fee would be perceived as a punishment given to the patient by the health professionals themselves.”
The study is part of the Ph.D.-project What is the normative foundation of nonattendance fees? at UiO. Fystro will later conduct a comparative study on the public non-attendance fee debates in Norway and Denmark, looking at public documents.
“Non-attendance fees have not been introduced in public hospitals in Denmark, as of today,” Fystro says. “We will also do a survey where we ask how a sample of the population perceives the non-attendance fee, before we do an ethical analysis of the non-attendance fee schemes.”
Joar Røkke Fystro et al, Mapping out the arguments for and against patient non-attendance fees in healthcare: an analysis of public consultation documents, Journal of Medical Ethics (2023). DOI: 10.1136/jme-2022-108856
Journal of Medical Ethics
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