Post on 13-Jan-2016
description
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