Equity impact of a choice reform and change in reimbursement system in primary care in Stockholm County Council

Abstract

BackgroundIn 2008 reforms were introduced in primary care in Stockholm County Council to increase patient choice. These reforms included changes to the reimbursement system from one that was primarily based on need-weighted capitation system (75 %) to a system largely based on fee-for-service (60 %) and freedom of establishment of primary care clinics. The new reimbursement system created incentives for producing many visits and additional primary care clinics were established, particularly in areas that were already well served. This study analyses if and how the choice reform and change of reimbursement system has affected equity in primary care consumption by investigating whether the increase in visits reflects levels of need and to what extent the reform have affected equity in health care between areas.MethodsCross-sectional data from the public health survey in Stockholm County 2006 (n = 34,707) and 2010 (n = 30,767) were linked to individual register data on socio-demographic characteristics and health care utilization in 2007 and 2011. Information on self-reported health status and disability pension was used as indicators of need of health care. Negative binomial regression was used to analyse the differences in GP visits between the two years.ResultsThe total number of visits to GPs increased by 46 % from 2007 to 2011 and the proportion visiting a GP increased by 17 %. Both men and women reporting poor mental health and women with limiting longstanding illness and poor self-rated health had significantly smaller increase in number of visits than healthy women and men. Men with poor health status living in disadvantaged areas had a smaller increase than men with poor health status living in other areas of Stockholm County.ConclusionsThe reform did not particularly benefit those with greater health care needs, and there are indications of a negative impact on equity in primary care after the introduction of the reform. There were signs of a lesser increase in total number of visits to GPs among those with poor mental health, among women with poor self-rated health and limiting longstanding illness, and among men living in disadvantaged areas.

The interaction effect of health insurance reimbursement and health workforce on health care‐seeking behaviour in China

“…These findings are consistent with those of studies showing that the introduction of primary care workers would increase health care utilization and outpatient visits at PHCs among patients with chronic diseases . In addition, studies in Sweden and Mexico have both indicated that government financial investment in PHCs can increase the number of visits to these facilities …”

“…16,30,31 In addition, studies in Sweden and Mexico have both indicated that government financial investment in PHCs can increase the number of visits to these facilities. 20,21 Second, the positive association between ARR at county hospitals and the probability of visiting those hospitals was stronger in areas with higher physician densities in the county hospitals. This finding has some implications for targeted health insurance improvement and health workforce allocation strategies.…”

“…17 While China's most recent health system reform was comprehensive, few studies have systematically quantified the impact of this reform on health care-seeking behaviour. The majority of studies in China and other developing countries have focused on individual health reform policies, such as reform of health insurance 4,5,[18][19][20][21] or investment in health workforce. 15,16 Several studies have assessed the effects of the health reform on health care access from a system-wide perspective; however, what is the relationship between specific health policies and health care-seeking behaviour is not examined.…”

Equity aspects of the Primary Health Care Choice Reform in Sweden – a scoping review

“…no. Year Area(s) Data Focus Results Scientific articles Beckman, Anell [ 23 ] 2013 Region Skåne Population register data Process of care – PHC visits Visits increased more among high-income than low income earners Agerholm et al [ 25 ] 2015 Stockholm County council Population register data, public health survey data Process of care – PHC visits Visits increased more among person with lesser needs; less among those with greater needs Glenngård [ 32 ] 2013 Region Halland, Skåne, Västra Götaland Patient survey data Outcome – Patient satisfaction Satisfaction with primary care higher in areas with low level of social deprivation and in smaller practices Maun et al [ 27 ] 2013 Gothenburg Interviews with 24 PHC managers Process of care – doctors’ views Prioritisation conflicts among doctors between patients with different needs and demands. Chronically ill patients were crowded out.…”

Planned and Unplanned Hospital Admissions and Their Relationship with Social Factors: Findings from a National, Prospective Study of People Aged 76 Years or Older

“…Sweden has a universal, comprehensive, and mainly tax‐financed health care system in which services should be accessed based on need, regardless of economic or social resources, although studies have shown that this objective has not been fully reached (e.g., Agerholm et al. ). Copayments exist, but are small (≈4 percent), and those with extensive health care needs are covered by a national high‐cost protection (ceiling set at SEK 1,100, after that no further charges for the remainder of the 12‐month period).…”