Primärvårdens resurser, styrning och organisation : En jämförelse av villkor och förhållanden i Danmark, Norge, Nederländerna och Storbritannien

Myndigheten för vård- och omsorgsanalys (Vårdanalys) har vänt sig till professor Anders Anell vid Lunds universitet för att genomföra fallstudier av primärvården i fyra länder: Danmark, Norge, Nederländerna och Storbritannien. Denna promemoria är hans redovisning av arbetet och är ett underlag till Vårdanalys rapport En primär angelägenhet. Kunskapsunderlag för en stärkt primärvård med patienten i centrum (Rapport 2017:3)

Hälsoval skåne : Fler besöker allmänläkare, färre går till specialist

Efter införande av Hälsoval Skåne har andelen av befolkningen som besökt allmänläkare ökat, liksom antalet besök per invånare. Ökningarna är överlag måttliga, med undantag för äldre män med lägre inkomst, där ökningen är större.Det finns också en minskning av besöken till övriga specialistläkare så att det totala antalet läkarbesök per invånare minskat i vissa grupper. Färre besök hos övriga specialistläkare har inte fullt ut kompenserats av fler besök till allmänläkare.Uppföljningstiden är kort, och nya uppföljningar av individers totala konsumtion av vård med senare och ytterligare data är angelägna för att studera förändringar till följd av Hälsoval

Information, Switching Costs, and Consumer Choice : Evidence from Two Randomized Field Experiments in Swedish Primary Health Care

Consumers of services that are financed by a third party, such as publicly financed health care or firm-sponsored health plans, are often allowed to freely choose provider. The rationale is that consumer choice may improve the matching of consumers and providers and spur quality competition. Such improvements are contingent on consumers having access to comparative information about providers and acting on this information when making their choice. However, in the presence of information frictions and switching costs, consumers may have limited ability to find suitable providers. We use two large-scale randomized field experiments in primary health care to examine if the choice of provider is affected when consumers receive comparative information by postal mail and small costs associated with switching are reduced. The first experiment targeted a subset of the general population in the Swedish region Skåane, and the second targeted new residents in the region, who should have less prior information and lower switching costs. In both cases, the propensity to switch provider increased significantly after the intervention. The effects were larger for new residents than for the general population, and were driven by individuals living reasonably close to alternative providers

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study

Objective A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed. Design and setting Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county. Subjects A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units. Main outcome measures Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL). Results In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001). Conclusion P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated

General practice in the Nordic countries

<p><span lang="EN-GB">Background: General practice systems in the Nordic countries share certain common features. The sector is based on the Nordic model of a tax-financed supply of services with a political objective of equal access for all. The countries also share the challenges of increased political expectations to deliver primary prevention and increased workload as patients from hospital care are discharged earlier. However, within this common framework, primary care is organized differently. This is particularly in relation to the private-public mix, remuneration systems and the use of financial and non-financial incentives. </span></p><p><span lang="EN-GB">Objective: The objective of this paper is to compare the differences and similarities in primary care among the Nordic countries, to create a mapping of the future plans and reforms linked to remuneration and incentives schemes, and to discuss the pros and cons for these plans with reference to the literature. An additional objective is to identify gaps in the literature and future research opportunities. </span></p><p><span lang="EN-GB">Results/Conclusions: Despite the many similarities within the Nordic health care systems, the primary care sectors function under highly different arrangements. Most important are the differences in the gate-keeping function, private versus salaried practices, possibilities for corporate ownership, skill-mix and the organisational structure. Current reforms and political agendas appear to focus on the side effects of the individual countries’ specific systems. For example, countries with salaried systems with geographical responsibility are introducing incentives for private practice and more choices for patients. Countries with systems largely based on private practice are introducing more monitoring and public regulation to control budgets. We also see that new governments tends to bring different views on the future organisation of primary care, which provide considerable political tension but few actual changes. Interestingly, Sweden appears to be the most innovative in relation to introducing new incentive schemes, perhaps because decisions are made at a more decentralised level.</span></p

Development of Voluntary Private Health Insurance in Nordic Countries - An Exploratory Study on Country-specific Contextual Factors

The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors