Sending a Signal: The Effect of Raising Non-attendance Fees in Swedish Health Care

Abstract: In this paper, we study the effect of raising the fee for non-attendance on non-attendance rates in health care from a Swedish perspective. We do this by using a difference in difference design and exploiting a natural experiment in Sweden, where one county increased non-attendance fee to the double and the other county had a constant fee. Data on individual level allows us to investigate a general effect as well as heterogeneity in treatment depending on age and tendency to miss appointments in the past. The theoretical framework departs in neoclassical theory and the deterrence hypothesis, which predict that patients will decrease their rate of non-attendance. Meanwhile, behavioral research shows that an external incentive can crowd out intrinsic motivation. The theoretical predictions of the effect of a fee are therefore ambiguous and previous research on the field is scarce. Our study can contribute with generalizable evidence from both primary and secondary care in Sweden. The results are a decrease in non-attendance rate by 39% when doubling the non-attendance fee. Skåne County implemented the reform and using back of the envelope calculations indicate cost reductions estimated to at least 69.2 million SEK annually. We draw the conclusion that monetary sanctions have a large effect on non-attendance rates and signaling, through media and in the health care organization, might have enhanced the effect.