Learning from Swedish Health Care Staffan Bjessmo, MD, PhD Cardiothoracic Surgeon Chief Medical Officer, Synergus AB CEO, CollaboDoc AB 1
Agenda Overview of Swedish Health Care System How decentralized system is functioning? How health care is funded? How Hospital is Managed? Experience from Medical Services of Gotland Island an Uppsala Academic Hospital How care is provided in remote areas? IT in health care and telemedicine 2
Sweden is among countries with relatively high spending on health care (9.1% of GDP in 2008) 82% comes from public sources (one of the highest indicator in Europe) 3
Satisfaction with Health Care Services 4
Person ID Enabling Service Review and Research Personal identity number unique 10-digit code Used by tax, govern, health care, eduction and other authorities; banking, post service etc. Existence of personal identity number can facilitate analysis of health care resource consumption for quality management in health care, as well as researches and live patient registries 5
Reimbursement Model is decided locally The 21 County Councils/Regions are responible for providing and funding healthcare. Each County Council/Region sets up contracts with the public (and private) hospitals in its geographic area and decides how to fund the care. The most common model is funding through Global Budgets. DRGs are used in all County Council/Regions in order to monitor and report costs and decide reimbursement tariffs and budgets for following years. MAIN REIMBURSEMENT MODELS Global Budget Activity Based Budget (DRGs) Mix of above 6 Copyright Synergus
How Hospitals are Managed? Experience Medical Services of Local Hospital and University Hospital Elected politicians in the County councils are responible for setting the frame What healthcare should be delivered How much can it cost ( tax income) Hospital executives is are responsible for the management of the hospital How shall the healthcare be delivered How to prioritize What should be invested in? What should be skipped?? 7
Health Care Management in Sweden- a Political Arena Good health care is of great importance for the Swedish population The population is used to high level, first class care Always a top topic in political elections Tax payment versus private. Profit versus non profit. 8
How To Manage Highly Specialized Cardiac Care? 9
Cardiothroracic Surgery Clinic in Uppsala 350 employees 400 M SEK revenue 800 Open Cardiac surgeries 200 Pulmonary surgeries Intensive Care and postoperative ward 10
Manage the Clinic- a Balance Act Budget given from head of surgical division Responsible for both quality of surgical care, keeping budget and personell Different perceptions of what is important is often discussed, and not always agreed on In the end of the day, most important is to provide high level, and safe care for the patients Registries are important, aline care in Sweden 11
National Quality Registries The National Quality Registries have been developed to fill the gap left by the lack of primary monitoring systems. Executive Committee for National Quality Registries oversees and finance this activity Currently there are 73 National Quality Registries, which are managed by 8 competence centers 12
Uppsala Clinical Research and Registry Center RIKS-HIA Registry on Cardiac Intensive Care [Register of Information and Knowledge about Swedish Heart Intensive care Admissions] SEPHIA Registry on Secondary Prevention in Cardiac Intensive Care [Secondary Prevention in Swedish Heart Intensive care Admissions] Swedish Heart Surgery Registry SCAAR Swedish Coronary Angiography and Angioplasty Registry Swedvasc Vascular Registry in Sweden RiksSvikt National Heart Failure Registry GUCH Grown-Up Congenital Heart disease Registry Swedevox Respiratory Failure Registry GallRiks Swedish Quality Registry on Gallstone Surgery SveDem Swedish Dementia Registry AuriculA Atrial Fibrillation Register Webrehab Sweden Quality Registry in Rehabilitation Medicine Senior Alert National Registry on Nutrition, Fall Prevention, and Pressure Sores National Catheter Ablation Registry Lung Cancer Registry Registry on Hydrocephalus and Arteriovenous Malformations in the Brain Pulmonary Hypertension Registry SITS International Registry on Thrombosis in Stroke [Safe Implementation of Thrombosis in Stroke] EQUIP International Registry on Cardiac Intensive Care ERAS International Registry on Colorectal Surgery [Enhanced Recovery After Surgery]. 13
Data Available in Scandinavian Obesity Surgery Registry 14
Stakeholders Politicians Hospital executive Doctors Nurses etc 15
Management at Gotland Island 16
Visby Hospital 17
Remote Location How to Deal With That? Collaboration important! Physician training constantly at larger institutions Helicopter service for acute cases Extra doctors and nurses from Mainland constantly working at the hospital Engagement in research projects and quality registries Telemedicine of growing interest- but still limited» Surgical collaboration» Endoscopy 18
IT in Health Care All patient records in Sweden computerized Access to investigations important Different systems is a hurdle Personal identification number make access easier 19
The Future- IT Structure Supporting Collaboration in Remote Areas All patient can get a high level, specialist recommendation at the GP office Internet based, in real time, instant Evidence based recommendations Experienced specialist clinicians can support general practitioners, regardless of location The right diagnosis and treatment immediately will save money 20
Right Care Provided - Regardless of Location 21
What is the Source of Money for the Country Councils? User charges and other charges 2% Other 2% Sales and other revenues 4% Subsidies 3% General state grants 17% Taxes 72% 22 SALAR, 2010.
Spending Domains (Proportion of Total Spending, 2009) Capital formation of health care provider institutions 4% Home or domicilary health services 8% Health administration and insurance 1% Other 7% Public health and prevention 4% Prescribed drugs 9% Ancillary services 4% Inpatient care 27% Outpatient dental services 8% Outpatient services 28% 23 Statistics Sweden, 2010.
Co-Payment as a Percent of the Total Cost, 2009 70,00% 60,00% 59,47% 50,00% 40,00% 30,00% 25,91% 20,00% 10,00% 0,00% 3,71% 1,48% 1,30% Primary care Somatic specialized care Psychiatric care Outpatient dental care Prescribed pharmaceuticals 24 National Board of Health and Welfare (pharmaceuticals); Statistics Sweden, SCB (dental care) and the SALAR (the rest).
Healthcare Financial Flow Taxes National Government Employer Payroll fees State Grants State Grants National Social Insurance Board Income Taxes County Councils (17) & Regions (4) Income Taxes Municipalities (290) Public and private care of elderly and disabled Mixed payment Population Employers User Charges Public and private primary care Public and private specialized care Mixed payment Mixed payment Public and private dental care Fee for Service, < 20 years Subsidies Patients Prescribed pharmaceuticals, OTC drugs and disposables Subsidies 25 Source: Healthcare Systems in Transition, Sweden
The Swedish Healthcare system 2012 Provision and financing of hospital care is decentralized and is the responsibility of each of the 21 Swedish counties Central Government SBU Dental & Pharmaceutical Benefits Board Each of the 21 county councils (regions) are the key decision-makers regarding financing and provision of healthcare. The Ministry of Health and Social Affairs Develops, supervises and implements health policies. National Ministry of Health and Social Affairs National Board of Health and Welfare Medical Products Agency The Dental and Pharmaceutical Benefits Agency (TLV) is the responsible authority for subsidization of drugs and certain types of medical devices. Payer: SALAR The National Board of Health and Welfare is the authority for supervision and evaluation. Regional ayers Local University Hospitals (7) Private Hospitals (6) County Councils (17) & Regions (4) Providers District County Hospitals (70) Pharmacies (1200) Primary Care Centers (1100) Payer: Municipalities (290) Providers Care for Elderly and Disabled SALAR is the.swedish Association of Local Authorities and Regions The Medical Products Agency administrates approval of drugs, reviews risk management and clinical trials for medical devices. SBU - The Swedish Council on Technology Assessment, the national HTA agency. 26 Copyright Synergus
DRGs are Only Used as a Means of Reimbursement in a Few Selected Regions Others Use Global Budgets Note: The vast majority of counties do not use DRGs for reimbursement but rather finance their hospitals based on global budgets. Medical Device (Manufacturer) Professional Societies Healthcare Provider Covered sufficiently by DRG Yes Key counties using DRGs are Stockholm county, Västra Götaland county (Gothenburg) and Skåne county (Malmö). DRG-change (review by NBoH) Procedure code change (NBoH) No The NordDRG system is owned and maintained in collaboration between Sweden, Norway, Finland, Denmark and Iceland. Although the grouping logic and number of DRGs is mostly the same in all countries, tariffs are defined nationally. Evaluation of proposition by NCCH and/or Nordic Casemix Centre New/split NordDRG Application for funding at hospital level or county level 1 Hosp. Board of Directors or County Council reviews application Reimbursement Reimbursement Reimbursement 27 MoH, Ministry of Health; and Social Affairs NBoH, National Board of Health, NCCH, Nordic Centre for Classifications in Health Care Copyright Synergus
The NordDRG Reimbursement System Used in Sweden is Maintained Collaboratively Between the Nordic Countries NordDRG, Activity based hospital financing system Diagnosis code (s) ICD-10 Procedure code (s) NCSP / KMÅ Patient specific parameters Grouping Nord DRG group Reimbursement Although the majority of procedure codes and DRGs remain the same between the Nord DRG countries, each market also defines a set of codes that are specific to each market. The NCSP (Nomesco classifications of surgical procedures) nomenclature is uniform for all markets, while certain non-surgical procedure codes (KMÅ) are specfic for Sweden. The DRGs are also mostly the same, although some local code differences exist. 28 Copyright Synergus
29 Thank You!