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Equity in health care ─ a matter of choice of health care unit?

Equity in health care ─ a matter of choice of health care unit?. Monica Löfvander, senior lecturer, docent in general practice Centre for Clinical Research Dalarna Falun Sweden. Studies show that. Patients want to be involved in own treatment

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Equity in health care ─ a matter of choice of health care unit?

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  1. Equity in health care ─ a matter of choice of health care unit? Monica Löfvander, senior lecturer, docent in general practice Centre for Clinical Research Dalarna Falun Sweden

  2. 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

  3. The new lawa • 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”

  4. The new law threatens: • Good care on equal terms for all • Primary health care as a specialty Back to Stockholm county . . .

  5. Good care on equal terms for all? • Sweden is very segregated • Stockholm County (2 million) especially segregated • Wealth and Health differs widely • Mean annual sick leave: 54 vs.10 days • Suicidal thoughts: 8% vs. 2% • Smoking: 30% vs. 10%

  6. 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

  7. Cultural barriers to seeking care • Economic • Language • Prejudices Other challenges: • Mis-interpretations of patients’ medical history, idioms, behavior, migration process, endemic disorders

  8. Reimbursement in Stockholm County Fixed • Per capita and by age with lowest reimbursement for persons of working age Floating • By number of visits • By number of interpreter hours • By measured quality (???) parameters Other roads for imbursement • Care Need Index • Adjusted Clinical Groups

  9. 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)

  10. Access to primary care 2008 • 0.9 PHC per 10 000 inhabitants (poor areas) • 1.2 PHC per 10 000 inhabitants (wealthy areas)

  11. AND . . . Fewer but also smaller PHCs in poor areas drained of competent professionals

  12. 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)

  13. 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

  14. Thank you! • Thank you

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