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Exit versus Voice: Competition and Dissatisfied Patients’ Responses to General Practitioners


Tigist Woldetsadik Sommeno

University of Oslo (UiO), NO
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Abstract: Background: Hirschman’s 1970; 1980 analytical conceptualization of the influence of competition on exit vs. voicing, the point of departure for this study, suggests that the presence of competitive providers’ fosters patients’ decisions to switch GPs exit. In Norway, the list patient system introduced in 2001 gives patients the option of changing GPs up to twice within a year. Although patient exiting can signal dissatisfaction with a particular GP, this signal is less informative about which aspect of the service is the issue. A private web-based rating site, Legelisten, was launched in Norway in May of 2012 to give patients a platform for voicing their opinions about the health care they receive, thereby also providing feedback that doctors can use to improve their services. Higher exit opportunities in a competitive market can reduce a patient’s motivation to voice about his or her provider; however, online voicing creates available knowledge about GPs and becomes a public good of high interest, especially in large-market settings, leading to higher participation in voicing in these markets than in smaller ones.

Objective: The study aims to test the influence of GP market competition on dissatisfied patients’ choice to exit switch physician or to voice participate in online rating.

Method: A panel data set covering the entire population of Norwegian GPs was utilized for every half year from January 2010 to January 2015 for patient exiting and from January 2012 to January 2015 for patient voicing.  The analysis was primarily quantitative, involving descriptive statistics and appropriate panel regression methods for both GP and market-level analyses multilevel mixed-effect linear regression for the GP-level exit, multilevel mixed-effects logistic regression for the GP-level voice, linear regression for the market-level exit, and the Tobit regression for market-level voice.

Findings: Higher GP market competition both with and without adjusting for municipality size increased the proportion of patients switching exit.  However, for voice, higher GP market competition not adjusted for municipality size led to more participation for both dissatisfied and overall voice, while adjusted for municipality size led to less participation. This opposite effect, reflects the municipality size effect and the associated difference in the public good motive for contributing to the online voice. This result is consistent in both the GP-level and market-level analyses, strongly supporting the hypothesis adopted by this study. 

How to Cite: Woldetsadik Sommeno T. Exit versus Voice: Competition and Dissatisfied Patients’ Responses to General Practitioners. International Journal of Integrated Care. 2018;18(s2):200. DOI:
Published on 23 Oct 2018.


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