Swedish health care system Charlotta Levay Harkness Fellowship Orientation Seminar New York September 2013

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Growing & ageing population 9,6 million, increasing due to immigration 15 % born abroad More than 80 % live in urban areas > 65 expected to increase from 19 to 25 % until 2020 > 80 expected to double to 10 % until 2040 Challenge to health care provision and financing Hot topic: how to extend working age span

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Public & decentralised health care system National government – Overall policy: law, decrees & agreements with SALAR, the Swedish Association of Local Authorities and Regions 21 county councils/regions – Organise, provide and finance health care for all residents – “HMOs” with taxation powers and elected bodies – Increasingly outsourced services (12 %) but limited private insurance (4 %) 290 municipalities – Organise, provide and finance care for elderly & disabled – Taxation powers and elected bodies

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Primary care: privatisation & patient choice Patient choice of provider + freedom of establishment (law 2010) Public and private providers paid by county councils Varying mix of capitation, pay/visit and targets County councils decide principles of accreditation, listing, payment, co-payment, etc. Most GPs are salaried by public provider or for-profit corporation GPs have no effective gate-keeping function

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Public hospitals and increasingly outsourced specialised care 60 acute care hospitals – Specialised services – Owned by county councils/regions; one privately run – Salaried doctors and professionals Increasing outsourcing & patient choice – Elective care outsourced to mostly for-profit providers – National incentives for local patient choice reform Payment mechanism vary across county councils – Move from global budgets to mix of DRG-based per-case payment, price/volume ceilings and quality components

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Fundamental cost-containment elements Health care expenditure 10 % of GDP County councils & municipalities are integrated systems, required to balance budgets and prioritise Virtual monopolies & monopsonies (single buyers) Co-payment Specialised care: global budgets or pay/case + ceiling Primary care: capitation Most health professionals are salaried Medicine subsidised according to cost/QUALY

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Recent reforms focus on improved access and coordination Renewed ‘Queue Billion’ – USD 160 million/year in state incentives to county councils that comply with waiting-time guarantee – Clearly reduced hospital waiting times in past 2 years – Recentralisation; model for new reforms Coordinated care for the most ill elderly people – Focus on discharge policy – State resources for health and social care cooperation – State incentives to local governments reaching targets on readmission, quality measures, quality registries, etc.

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Quality initiatives underway: consensus and (some) divergence Continued choice and privatisation to improve access – Some county councils still busy with primary care reform – Other county councils moving ahead in specialised care – Priority of present government; national election in 2014 Emerging performance paradigm – Multitude of reforms to stimulate quality registries, transparent comparison, value for money, health outcomes from patient perspective, process orientation and coordinated services Lurking: restart of pending regionalisation

Harkness Orientation Seminar September The Swedish Health Care System – Charlotta Levay Selected readings Anell A., Glenngård A.H. & Merkur S. (2012). Sweden: Health System Review. Health Systems in Transition, 14(5):1–159. European Observatory of Health Systems and Policy. Blomqvist P, Winblad U. (2013). Sweden: Continued Marketization within a Universalist System. In Pavolini E & Guillen A.M. (eds.). Health Care Systems in Europe. Institutional Reforms and Performances. Palgrave (forthcoming). Fredriksson, M., Blomqvist, P. & Winblad, U. (2013). The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice. Journal of European Social Policy, 23(2): 192–209. Saltman, R.B., Bergman, S.-E. (2005). Renovating the commons: Swedish health care reforms in perspective. Journal of Health Politics, Policy and Law, 30(1-2): 253–276. Winblad U, Hanning M. (2013). Sweden. In Siciliani L, M. Borowitz & V. Moran (eds) Waiting Time Policies in the Health Sector: What Works? OECD Health Policy Studies, OECD Publishing.