Equity in health care ─ a matter of

choice of health care unit?

Monica Löfvander, senior lecturer, docent in general practiceCentre for Clinical Research Dalarna FalunSweden

Studies show that

• Patients want to be involved in own treatment

• Choice systems did not affect efficiency or quality of care

• Privileged populations took the opportunity to choose

• Choice systems increased inequality in care• Refunding systems can reduce inequality

The new law a

• Patients will choose primary health care unit, not physician

• Units need at least one specialist in primary health care/GP b

• Reimbursement and practical systems will differ by county

a ”lagen om valfrihetssystem (LOV)” b ”Läkarkontakt behöver ej vara specialist i allmänmedicin”

The new law threatens:

• Good care on equal terms for all

• Primary health care as a specialty

Back to Stockholm county . . .

Good care on equal terms for all?

• Sweden is very segregated Sweden is very segregated

• Stockholm County (2 million) especially Stockholm County (2 million) especially segregatedsegregated

• Wealth and Health differs widelyWealth and Health differs widely– Mean annual sick leave: 54 vs.10 days Mean annual sick leave: 54 vs.10 days – Suicidal thoughts: 8% vs. 2%Suicidal thoughts: 8% vs. 2%– Smoking: 30% vs. 10%Smoking: 30% vs. 10%

Average visits to primary health care center per year

Age Stockholm County Rinkeby

0-24 1.7 2.0

25-44 1.8 2.4

45-64 2.7 3.6

65 + 4.9 6.1

Cultural barriers to seeking care

• Economic

• Language

• Prejudices

Other challenges:

• Mis-interpretations of patients’ medical history, idioms, behavior, migration process, endemic disorders

Reimbursement in Stockholm CountyFixed • Per capita and by age with lowest reimbursement for

persons of working ageFloating• By number of visits• By number of interpreter hours • By measured quality (???) parameters

Other roads for imbursement• Care Need Index • Adjusted Clinical Groups

HED = Behaviour that results from the Stockholm model

• “Hunting” patients for the unit (not the doctor)

• “Emphasizing” change of choice (the winning unit of the month gets the capita money)

• “Dollar eyes” (non-GPs, overuse of interpreters, quicker visits, no “difficult” patients, no QI work or research, less staff)

Access to primary care 2008

• 0.9 PHC per 10 000 inhabitants (poor areas)

• 1.2 PHC per 10 000 inhabitants (wealthy areas)

AND . . .

Fewer

but also smaller PHCs in poor areas drained of competent professionals

AND . . .

●This inequity will be sustained for many years

●This development can be countered by reimbursement per capita and use of need (CNI) and diagnosis indexes (ACG)

Threats to the primary care specialty

• Law requires only one GP specialist per unit

• Other health professionals and EU doctors hired instead of primary care specialists

• Research and development work becomes economically undesirable

• Can be countered by reimbursement system

Thank you!

• Thank you