Over the last two years, the academics Pablo Celhay and Nicolás Figueroa, from the Markets, Organization and Regulation research line at the Complex Engineering Systems Institute (ISCI), carried out research aimed at analyzing the data of sick leave granted in Chile through the National Health Fund (Fonasa). Their research revealed two situations: Firstly, there are certain pathologies where a high variability is detected in the number of days of leave granted by doctors, and, secondly, a nationwide market exists for leave issued by doctors with an anomalous emission level regarding codes for certain ailments that lack specific tests for verification.
Based on this data, the academics designed an experimental intervention, using pop-up alert messages sent to the healthcare professional issuing leave electronically, bringing with it a 20% reduction of sick leave issued by a group of doctors selected for the implementation of the measure. This intervention translated into potential savings of USD $100 million per year for Fonasa during 2022.
Context
In 2020, researcher Pablo Celhay reached an agreement with Fonasa that gave him full access to duly anonymized sick leave data issued to its affiliates throughout Chile. This included information from over 50,000 doctors, the patients to whom temporary leave was granted, and their pathologies.
In Chile, 80% of the population is affiliated with the National Health Fund, and that number is increasing as a consequence of the Isapre (private healthcare companies) crisis. In 2022, sick leave was granted to more than 9 million people in the system.
Chile has particular conditions that facilitate the granting of sick leave, which opens the door to a misuse of this instrument. On the one hand, a high percentage of the population is in formal employment. On the other, any doctor can grant sick leave, unlike state-controlled health systems.
Based on the analysis of the data, the researchers conceived an experimental intervention where two research questions were established: Could a reference and information system on the normal duration of sick leave reduce the number of people granted an excessive number of days? Is it feasible to regulate the behavior of doctors who issue an excessive amount of sick leave by way of low-cost monitoring interventions?
This project was submitted to the Impact Evaluation Fund contest of the Budget Directorate of the Ministry of Finance (Dipres) and the National Research and Development Agency (Anid) and was awarded in 2021.
Experimental Intervention
Researchers Pablo Celhay and Nicolás Figueroa worked with Fonasa on the design of an experimental intervention based solely on information provided to doctors. After determining and selecting target groups of doctors, they opted for two types of simple interventions conducted through software from the electronic licensing provider (Imed). Each of them would have a duration of 12 months, with implementation commencing during 2022.
The first intervention was carried out over a one-year period and consisted of an alert system directed at healthcare professionals, with online notifications and recommendations. The aim was to improve the process of issuing sick leave and focused particularly on doctors who issued an amount equal to or greater than the 70th percentile of the national distribution of leave days for a specific diagnosis, therefore deeming it excessive.
This intervention included two different treatments: one that provided real data and another that also incorporated a social norm component, which is to say, comparing sick leave with the average for a specific diagnosis.
Both treatments were found to have a statistically significant impact on reducing the length of sick leave that exceeded the 70th percentile, which implied that leave became less extensive as a result of the notifications. However, an interesting side effect was observed. For sick leave below the 70th percentile, the duration increased as a result of the intervention. When these two effects were considered together, it was concluded that the interventions did not have an overall statistical effect different to zero.
This suggests that the duration-increasing effect on leave below the 70th percentile counteracted the duration-reducing effect on licenses above this threshold, compared to the original situation.
This successful result is contrasted with other interventions analyzed in the literature, where doctors follow the length of leave established in a medical guide prepared by a renowned institution. In those cases, doctors pay little attention to the recommendation. It seems, therefore, that there are powerful mechanisms in place that reduce the days that exceed the necessary period, and that they resort directly to the day-to-day practices of peers and not to guides that are perceived as “theoretical” by doctors.
A second intervention was conducted with the doctors who issued the greatest number of leave days in the country. It was estimated that around 1% of the doctors who work under an agreement with Fonasa accounted for 35% of total medical leave in 2022.
The researchers focused on doctors who were among the top 5% of issuers in 2019. This group was divided into three. Along with a control group, two messages were created and sent to healthcare professionals. The second group was simply reminded that they were among the doctors with the highest national rate of issuance. The last group was also reminded that Fonasa had the power to intervene.
“The interesting thing about our proposal is that it is a soft intervention, without threats of any kind, but with a message that lets the issuer know that their behavior is not going unnoticed in the system. After twelve months, we observed a 12% decrease in sick leave in the case of the first message, and in the case of the second message, it brought a 20% decrease. Sending these messages was enough to generate a change in the behavior of these doctors,”
explains Pablo Celhay.
“A couple of years ago, the Commission of Preventive Medicine and Disability (COMPIN) filed a complaint against doctors suspected of issuing unjustified leave and prevented them from doing so for several months. That was a much tougher measure, which achieved similar results to those that we obtained in a less aggressive manner, without the need for judicial action,”
says Nicolás Figueroa.
The measure brought a direct potential saving of US$100 million, but it could be even more if this type of intervention is scaled up and bolstered by effective inspections.
“This figure is significant, since around half of the contributions received by the National Health Fund is used to cover sick leave. The reduction in unjustified leave allows would allow these resources to be redirected to other areas of the system, such as the coverage of the benefits of its members,”
reflects Nicolás Figueroa.
Upcoming Challenges
Although the intervention shows a marked decrease in unjustified leave in the medium term, it does not generate a structural change.
“We as a team feel there are questions that need to be answered. What do patients looking for sick leave do when a particular physician changes his or her behavior following the experimental intervention? Logic leads us to think that new providers will appear, so we would be interested in working on new interventions that include a patient profile. When you intervene in only one side of the market, where the demand is with the patients and the supply comes from doctors who often grant sick leave, you do not necessarily generate a decrease that is maintained over time. We also wonder how long the effect of these interventions on health professionals would last and whether they would relapse in their behavior. And, finally, what needs to be done in parallel to complement this measure and allow long-term changes in the healthcare market?”,
concludes Pablo Celhay.