reform in Sweden Lund university school of economics and management

Transcription

1 The effects of 2010 primary care reform in Sweden Anders Anell Lund university school of economics and management

2 Problems in Swedish primary care ca Weak development from historical perspective Specialists important provider of out patient services Gap between resources and mission/tasks Financial resources, number of GPs, trust Changing conditions since mid 1990s Shift of services from hospitals (chronic diseases, elderly) Increased demand from population Uncertainty regarding future development Patient choice or geographical responsibility? Choice of GP or practice/unit? Private or public? 1. Anell, A. (2005) Primärvård i förändring. Studentlitteratur: Lund.

3 New models based on choice in Swedish primary care from 2007 Started as local initiatives Halland (2007), Västmanland och Stockholm (2008) Picked up by other county councils e.g. Kronoberg, Region Skåne, Östergötland, Västra Götalandsregionen (2009) M d t b ti l l i l ti f J Mandatory by national legislation from January 1st 2010

4 Choice based models = several components National regulation Money should ldfollow choice of population lti Freedom of establishment for private providers that fullfil local requirements The rest determined by the 21 county councils Responsibilities and required competence for providers Payment to providers Importance of capitation vs. fee for service Risk adjustment ik of capitation i fee Financial responsibility of providers Registration with providers

5 Two models Stockholm Primary care divided in several sub parts 60% fee for service payment for family physicians Limited financial responsibility Active registration with family physician or practice Halland och other county councils Primary care providers have broad responsibility At least 80% of payment (up to 98%) based on capitation Comprehensive financial responsibility (fundholding, drugs budgets in several counties) Active or passive registration with practice/unit

6 Comprehensive payment py and economic incentives 1 Financial risk fully on providers Favours larger units and/or horisontal integration Increased risk of cream skimming behaviour Need for regulation and risk adjustment of payment Increased risk of under provision Cost shifting (e.g. through referrals) Skimping on quality 1. Anell, A. (2011) Choice and privatization in Swedish primary care. Health Economics, Policy and Law.

7 How to prevent under provision of care following comprehensive payment 1 Compliance towards clinical guidelines Including possibilities to conduct audits and exit rules for providers who are able to survive in spite of poor clinical performance Excemptions for high cost patients ( outliers ) And/or expensive medical technology Transparent comparison of quality indicators To support population choice and more Pay for performance f Linked to clinical targets 1. Miller H D (2009) From volume to value: Better ways to pay for health care. Health Affairs; 28(5):

8 If you want to send a message to a doctor, write it on a cheque. Former health minister in UK

9 There are many mechanims for paying physicians; some are good and some are bad. The three worst are fee-for-service, capitation, and salary. Robinson JC. Theory and Practice in the Design of Physician Payment Incentives. The Milbank Quarterly, 2001; 79 (2).

10 Different payment systems Description Implications from economic incentives Salary Pay independent of Do as little as possible for workload or quality as few as possible Capitation Pay according to Do as little as possible for number of people on as many as possible doctors list Fee for service P4P Pay for individual items of care Pay for meeting quality targets Do as much as possible, whether or not it helps the patient Carry out a limited range of highly commendable tasks, but do little l else Lecture by Prof. Martin Marshall, Forum for Health Policy, 20 september 2011, Stockholm.

11 What is the outcome of reform? Debate about pros and cons! About 250 new private providers Expansion of primary care Improved access for patients Improved productivity for tax payers Need more studies!

12 Evaluation of choice reform in Stockholm 1 Improved access to physician visits 10% productivity increase in2008; 3% in 2009 Positive correlation between increased productivity and patient satisfaction Increased proportion of primary care Improved access for all, but particularly in geographical areas with lower average income and among patients with significant health needs No significant difference in productivity between public and private providers 1. Rehnberg m fl. (2010) Uppföljning av husläkarsystemet inom Vårdval Stockholm redovisning av de två första årens erfarenheter. Karolinska Institutet 2010:12.

13 Distribution of doctor-visits in 19 OECD countries Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits to a doctor in 19 OECD countries van Doorslaer, E. et al. CMAJ 2006;174:

14 Two conditions for competition Individuals who are prepared to change between alternatives Willingness to change depends on information about alternatives At least two alternatives Threat from potential new competitors as important as existing alternatives (contestability)

15 Have you made a choice of practice/unit when primary care choice reform was introduced in your county council? Municipality Proportion Yes Halmstad 74% Hylte 47% Falkenberg 64% Totalt Halland 63% Malmö 61% Örkelljunga 62% Bromölla 60% Totalt Skåne 61% Göteborg 57% Uddevalla 56% Skövde 62% Totalt VG 59% A higher proportion of yes : - Among elderly and individuals with more doctor visits - In municipalities with new providers Source: Glenngård A, Anell A, Beckman A. (2011) Choice of primary care provider: results from a population survey in three Swedish counties. Health Policy.

16 From where did you get information about the practice/unit of your choice? Source of informaton At previous visits From friends/relatives From county council Advertisement in paper or other media I was contacted by the practice/unit My own search on the Internet Proportion 38% 23% 23% 14% 7% 3% Source: Glenngård A, Anell A, Beckman A. (2011) Choice of primary care provider: results from a population survey in three Swedish counties. Health Policy.

17 Respondents think they are informed enough (1= do not agree at all, 5= agree completely) Continuity in Too few alternatives Difficult to I have enough doctor relationship to choose coose Information to from choose Private providers are better Important to choose

18 Most of the 244 new private providers located in or around major cities. Source: Vårdföretagarna, Antal Nyetablerade Storstäder Förortskommuner Större Städer Pendlingskommuner Glesbygdskommuner Varuproduce erande kommuner Övriga kommuner 1 > inv Övriga kommuner inv. Övriga kommuner 3 < inv. 79 per cent of the new providers located in five county councils: Stockholm (65 new), Västra Götalandsregionen (47) Skåne (42), Halland (23) samt Jönköping (15).

19 Distribution between different types of ownership in Halland, Region Skane and VG region, december % 90 % 80 % 70 % 60 % 50 % 40 % 30 % Public National corp. Regional/local corp. Independent private 20 % 10 % 0 % Halland Skåne VGR Stockholm year 2009: 38% public, 32% independent private, 30% private chain. Source: Rehnberg m fl 2010.

20 Research themes in Vinnvård project about primary care reform Comparison between models Changesin county council governance of primary care Population use of option to choose primary care provider Effects on organization of primary care providers Effects on consumption of care by individual patients Effects on quality and efficiancy i of primary care and the health care system respectively