Anna Kollerup Iversen defends her PhD thesis


Anna Kollerup Iversen

Title: "Essays on Health Care: New insights into the economic burden of population ageing and the implementation of health policies aimed at promoting evidence-based clinical practice and consistency in the delivery of hospital care".

Time and place: 31 January 2022 at 10:00 AM.

To attend the PhD defense, please use this link:
Pass code: 1234

An electronic copy of the thesis can be obtained here:

Assessment Committee

  • Professor Mette Gørtz, Department of Economics, University of Copenhagen, Denmark (chairman)
  • Professor Mauro Laudicella, SDU, Denmark
  • Senior Research fellow, Daniel Avdic, Monash Business School, Australia


This thesis consists of three self-contained chapters. Each chapter casts light on different aspects of the challenges that national health authorities face in providing universal health care coverage under resource constraints and under the continual introduction of new knowledge and new expensive medical advances.

The first chapter is coauthored with Rikke Ibsen and Jakob Kjellberg. The demographic change towards a larger proportion of older individuals challenges universal health care systems in sustaining high-quality care and universal coverage without budget expansions. To build valuable predictions of the economic burden from population ageing, it is crucial to understand the determinants of individual-level health care expenditures. We examine static and dynamic health expenditure patterns across a 12-year period to shed light on future health care needs and threats to the sustainability of universal health care coverage. By applying individual-level administrative data from the entire Danish population, our study is the first to use a single data set to examine whether age, time to death and a steepening of the individual-level health care expenditure curve all contributed to individual-level health care expenditures over a 12-year observation period (2006–2018). We find that individual-level expenditures are associated with an individual’s age, an individual’s time to death and a steepening of the expenditure curve, with the steepening driven by individuals above age 75. We observe heterogeneity in the extent and age-distribution of the steepening across disease groups. The threefold combination of an ageing population, the correlation between expenditures and age per se, and a steepening of the expenditure curve make establishing financially sustainable universal health care systems increasingly difficult. To mitigate budgetary pressure, we suggest that policy-makers encourage cost-effective medical advances and health care utilization in the treatment of elderly people. Moreover, we suggest that future health care expenditure forecasts include scenarios with a steepening of the expenditure curve.
In the second chapter, I examine the effects of hospital clinic closures on patients living in municipalities where their nearest breast cancer clinic closes. Recent decades have seen a large number of hospital closures and consolidations, which have been carried out to stimulate returns to volume and specialization in hospital care. In the non-acute setting of scheduled breast cancer surgery, I examine how hospital clinic closures affect cost-saving metrics and the quality of care that closure-affected patients receive. The effects are identified using closures of breast cancer clinics in Denmark from 2000 to 2011, during which time the number of clinics was more than halved. Using event study designs, I examine changes in outcomes for patients living in municipalities where the nearest clinic had been closed. The results show that breast cancer clinic closures have been welfare-improving, as they have reduced the number of costly hospitalization days and shifted surgical procedures to state-of-the-art breast-conserving techniques without generating adverse health effects and without causing crowding in non-closing clinics. An examination of the mechanisms suggests that added volume returns at non-closing clinics were of less importance than simply reallocating patients to higher-quality clinics.

The third chapter is coauthored with Sarah Wadmann, Toke Bek and Jakob Kjellberg. Clinical practice variation has been problematized as a symptom of suboptimal care and inefficient resource spending. Therefore, consistency in the delivery of healthcare is a recurring policy goal. In the third chapter, we examine a case where the introduction of a new treatment is most likely to provide consistency in health care delivery because it was introduced with a national clinical practice guideline representing consensus about best clinical practice among leading clinicians, and because care delivery was highly centralized to few high-volume treatment units. Despite the consensus on best clinical practice and care centralization, this study shows pronounced regional variation in patient outcomes and treatment costs. Using a mixed-methods design, we find that the lack of consistency in care was largely unrelated to patient-specific characteristics, but seemed to reflect structural differences in the regional organization and financing of healthcare delivery. We conclude that the value of clinical practice guidelines is undermined when structural barriers limit the ability of clinicians and clinical managers to scale up treatment, and that some degree of decentralization may be a tool to maintain the treatment intensity when the treatment effect is dependent on a high treatment intensity.